Healthcare Provider Details

I. General information

NPI: 1285646661
Provider Name (Legal Business Name): TIM A BENGTSON O.D., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2006
Last Update Date: 05/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 E JACKSON ST
MACOMB IL
61455-2412
US

IV. Provider business mailing address

820 E JACKSON ST
MACOMB IL
61455-2412
US

V. Phone/Fax

Practice location:
  • Phone: 309-833-4242
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046007904
License Number StateIL

VIII. Authorized Official

Name: TIM BENGTSON
Title or Position: OWNER
Credential:
Phone: 309-833-4242