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General NPI Number Information
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NPI Number | 1093832008
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Entity Type | Organization
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Legal Business Name | J. MICETICH, OD & ASSOCIATES FAMILY EYE CARE CENTER P C
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Dates
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Enumeration Date | 03/23/2007
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Last Update Date | 09/18/2012
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Provider Practice Location Address
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Address Line | 20 E NORTH ST
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City | COAL CITY
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State | IL
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Zip | 60416-1087
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Country | US
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Telephone | 815-634-4825
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Fax |
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Provider Business Mailing Address
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Address Line | 2920 GATEWAY GORGE
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City | MORRIS
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State | IL
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Zip | 60450-9771
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Country | US
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Telephone | 815-634-4825
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Fax |
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Authorized Official
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Title or Position | OPTOMETRIST
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Name | DR. JONATHAN EDWARD MICETICH
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Credential | O.D.
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Telephone | 815-634-4825
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 046-008925
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License Number State | IL
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