Healthcare Provider Details

I. General information

NPI: 1205829389
Provider Name (Legal Business Name): HEYDE EYE CENTER S.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2005
Last Update Date: 06/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 NE SAINT MARK CT
PEORIA IL
61603-3717
US

IV. Provider business mailing address

400 NE SAINT MARK CT
PEORIA IL
61603-3717
US

V. Phone/Fax

Practice location:
  • Phone: 309-674-1234
  • Fax: 309-674-6422
Mailing address:
  • Phone: 309-674-1234
  • Fax: 309-674-6422

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number036075507
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. RAYMOND R HEYDE
Title or Position: OWNER
Credential: MD
Phone: 309-674-2244