Healthcare Provider Details

I. General information

NPI: 1255491775
Provider Name (Legal Business Name): BERGH-WHITE OPTICIANS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 05/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2351 W MONROE ST
SPRINGFIELD IL
62704-1452
US

IV. Provider business mailing address

2351 W MONROE ST
SPRINGFIELD IL
62704-1452
US

V. Phone/Fax

Practice location:
  • Phone: 217-787-8700
  • Fax: 217-787-8707
Mailing address:
  • Phone: 217-787-8700
  • Fax: 217-787-8707

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046008999
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046009181
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number046008999
License Number StateIL

VIII. Authorized Official

Name: MR. KENNETH F WHITE
Title or Position: VICE PRESIDENT
Credential:
Phone: 217-787-8700