Healthcare Provider Details

I. General information

NPI: 1518319029
Provider Name (Legal Business Name): ASHLEY AYLESWORTH O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2016
Last Update Date: 06/21/2024
Certification Date: 06/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2802 OUTER ROAD DRIVE
MARION IL
62959
US

IV. Provider business mailing address

2802 OUTER ROAD DRIVE
MARION IL
62959
US

V. Phone/Fax

Practice location:
  • Phone: 618-997-1081
  • Fax: 618-997-3481
Mailing address:
  • Phone: 618-997-1081
  • Fax: 618-997-3481

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046.011044
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: