Healthcare Provider Details

I. General information

NPI: 1366035644
Provider Name (Legal Business Name): PRAIRIE EYE CENTER, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2021
Last Update Date: 02/17/2021
Certification Date: 02/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

518 BROADWAY ST
LINCOLN IL
62656-2706
US

IV. Provider business mailing address

2020 W ILES AVE
SPRINGFIELD IL
62704-4174
US

V. Phone/Fax

Practice location:
  • Phone: 217-732-6062
  • Fax: 217-732-8495
Mailing address:
  • Phone: 217-698-3030
  • Fax: 217-698-3068

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: JASON LANG
Title or Position: BILLING ADMINISTRATOR
Credential:
Phone: 217-698-3030