Healthcare Provider Details

I. General information

NPI: 1225605637
Provider Name (Legal Business Name): SPENCER FAMILY EYE CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2021
Last Update Date: 06/06/2021
Certification Date: 06/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 W RANDOLPH ST
MC LEANSBORO IL
62859-1280
US

IV. Provider business mailing address

410 W RANDOLPH ST
MC LEANSBORO IL
62859-1280
US

V. Phone/Fax

Practice location:
  • Phone: 618-643-5113
  • Fax:
Mailing address:
  • Phone: 618-643-5113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL SEBASTIAN SPENCER
Title or Position: OWNER
Credential:
Phone: 618-439-7256