Healthcare Provider Details

I. General information

NPI: 1972550390
Provider Name (Legal Business Name): LIGHTS PROSTHETIC EYES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2006
Last Update Date: 07/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1318 W CANDLETREE DR STE 3
PEORIA IL
61614-8509
US

IV. Provider business mailing address

1318 W CANDLETREE DR STE 3
PEORIA IL
61614-8509
US

V. Phone/Fax

Practice location:
  • Phone: 309-676-3663
  • Fax: 309-676-0359
Mailing address:
  • Phone: 309-676-3663
  • Fax: 309-676-0359

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1700X
TaxonomyOcularist
License Number203000116
License Number StateIL

VIII. Authorized Official

Name: MR. RANDY L LIGHT
Title or Position: PRESIDENT
Credential: B.C.O., B.A.D.O.
Phone: 309-676-3663