Healthcare Provider Details

I. General information

NPI: 1447373378
Provider Name (Legal Business Name): LEBANON OPTOMETRIC CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2007
Last Update Date: 03/06/2020
Certification Date: 03/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 W SAINT LOUIS ST
LEBANON IL
62254-1515
US

IV. Provider business mailing address

201 W SAINT LOUIS ST
LEBANON IL
62254-1515
US

V. Phone/Fax

Practice location:
  • Phone: 618-537-6356
  • Fax: 618-537-6358
Mailing address:
  • Phone: 618-537-6356
  • Fax: 618-537-6358

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046007516
License Number StateIL

VIII. Authorized Official

Name: DR. CHARISSA THORPE
Title or Position: OWNER
Credential: O.D.
Phone: 618-537-6356