Healthcare Provider Details

I. General information

NPI: 1902009632
Provider Name (Legal Business Name): KEITH TYHURST O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2007
Last Update Date: 10/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 W DEYOUNG ST
MARION IL
62959-4437
US

IV. Provider business mailing address

1200 W DEYOUNG ST
MARION IL
62959-4437
US

V. Phone/Fax

Practice location:
  • Phone: 618-993-5686
  • Fax: 618-997-6250
Mailing address:
  • Phone: 618-993-5686
  • Fax: 618-997-6250

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046-009941
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: