Healthcare Provider Details

I. General information

NPI: 1609041342
Provider Name (Legal Business Name): OPTOMETRIC EYECARE INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2008
Last Update Date: 08/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 E MAIN ST
OLNEY IL
62450
US

IV. Provider business mailing address

303 E MAIN ST
OLNEY IL
62450-2117
US

V. Phone/Fax

Practice location:
  • Phone: 618-395-2676
  • Fax: 618-395-2720
Mailing address:
  • Phone: 618-395-2676
  • Fax: 618-395-2720

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046-008793
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number3840-6969
License Number StateIL

VIII. Authorized Official

Name: DR. CLARK E DESHON
Title or Position: PRESIDENT
Credential: O.D.
Phone: 618-395-2676