=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043324361
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VISION CENTER OF LOVES PARK, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/17/2006
-----------------------------------------------------
Last Update Date | 01/20/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11710 MAIN ST SUITE # 2
-----------------------------------------------------
City | ROSCOE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61073-9566
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-623-6060
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11710 MAIN ST SUITE #2
-----------------------------------------------------
City | ROSCOE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61073-9566
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-623-6060
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. RICHARD S. NEWCOMB
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 815-623-6060
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 346002079
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------