Healthcare Provider Details

I. General information

NPI: 1558462499
Provider Name (Legal Business Name): KEITH EDWARD KOWALSKE O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 N DRIES LN SUITE 101
PEORIA IL
61604-1259
US

IV. Provider business mailing address

3100 N DRIES LN SUITE 101
PEORIA IL
61604-1259
US

V. Phone/Fax

Practice location:
  • Phone: 309-688-6644
  • Fax: 309-688-6670
Mailing address:
  • Phone: 309-688-6644
  • Fax: 309-688-6670

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: