Healthcare Provider Details

I. General information

NPI: 1992736276
Provider Name (Legal Business Name): MARENGO VISION CENTER, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 08/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 N STATE ST
MARENGO IL
60152-2239
US

IV. Provider business mailing address

205 N STATE ST
MARENGO IL
60152-2239
US

V. Phone/Fax

Practice location:
  • Phone: 815-568-6508
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number060009322
License Number StateIL

VIII. Authorized Official

Name: DR. MICHAEL W. THOMAS
Title or Position: PRESIDENT
Credential:
Phone: 815-568-6508