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General NPI Number Information
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NPI Number | 1194054452
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Entity Type | Organization
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Legal Business Name | TRISTATE PROFESSIONAL SERVICES INC
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Dates
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Enumeration Date | 12/16/2009
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Last Update Date | 12/16/2009
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Provider Practice Location Address
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Address Line | 2760 N DIRKSEN PKWY ATTN: WALMART VISION CTR
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City | SPRINGFIELD
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State | IL
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Zip | 62702-1448
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Country | US
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Telephone | 217-522-4396
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Fax | 217-522-4861
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Provider Business Mailing Address
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Address Line | 508 E JACKSON ST
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City | RIVERTON
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State | IL
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Zip | 62561-8064
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Country | US
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Telephone | 217-259-8461
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Fax | 217-522-4861
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. ROBERT P EDWARDS
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Credential | OD
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Telephone | 217-259-8461
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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 | 046006399
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License Number State | IL
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