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General NPI Number Information
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NPI Number | 1114200896
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Entity Type | Organization
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Legal Business Name | SPECS CARTHAGE
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Dates
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Enumeration Date | 09/20/2011
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Last Update Date | 09/20/2011
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Provider Practice Location Address
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Address Line | 514 WABASH AVE
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City | CARTHAGE
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State | IL
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Zip | 62321-1360
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Country | US
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Telephone | 217-357-9750
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Fax | 217-214-9437
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Provider Business Mailing Address
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Address Line | 195 S 36TH ST
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City | QUINCY
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State | IL
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Zip | 62301-5801
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Country | US
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Telephone | 217-224-7732
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Fax | 217-214-9437
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Authorized Official
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Title or Position | OWNER
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Name | MR. DANIEL LEONARD HAYDEN
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Credential | OD
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Telephone | 217-357-9750
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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 | 046.009104
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License Number State | IL
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