Healthcare Provider Details

I. General information

NPI: 1356686604
Provider Name (Legal Business Name): REDWELL & WIETIES EYECARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2012
Last Update Date: 11/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905 W MEFFORD ST
ROBINSON IL
62454-1065
US

IV. Provider business mailing address

P.O. BOX 658 905 W. MEFFORD ST.
ROBINSON IL
62454-1065
US

V. Phone/Fax

Practice location:
  • Phone: 618-544-3525
  • Fax: 618-544-3261
Mailing address:
  • Phone: 618-544-3525
  • Fax: 618-544-3261

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046-008222
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046-007815
License Number StateIL

VIII. Authorized Official

Name: MR. WILLIAM H BEDWELL
Title or Position: PARTNER / OPTOMETRIST
Credential: O.D.
Phone: 618-544-3525