Healthcare Provider Details

I. General information

NPI: 1295802981
Provider Name (Legal Business Name): HENDERSON EYE CENTER P C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 12/05/2025
Certification Date: 12/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2709 S KOKE MILL RD
SPRINGFIELD IL
62711
US

IV. Provider business mailing address

2709 S KOKE MILL RD
SPRINGFIELD IL
62711
US

V. Phone/Fax

Practice location:
  • Phone: 217-698-9477
  • Fax: 217-698-9474
Mailing address:
  • Phone: 217-698-9477
  • Fax: 217-698-9474

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046-009151
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046008041
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number036-042254
License Number StateIL

VIII. Authorized Official

Name: DORSEY HENDERSON
Title or Position: MANAGER
Credential:
Phone: 217-698-9477