Healthcare Provider Details

I. General information

NPI: 1609152966
Provider Name (Legal Business Name): INTERNATIONAL EYECARE CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2011
Last Update Date: 01/22/2021
Certification Date: 01/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 W MAIN ST
MT STERLING IL
62353-1223
US

IV. Provider business mailing address

105 W MAIN ST
MT STERLING IL
62353-1223
US

V. Phone/Fax

Practice location:
  • Phone: 217-773-3055
  • Fax: 217-773-3522
Mailing address:
  • Phone: 217-773-3055
  • Fax: 217-773-3522

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: CATHY LEE SHORT
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 618-462-9818