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General NPI Number Information
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NPI Number | 1306057302
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Entity Type | Organization
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Legal Business Name | TRI-STATE OPTOMETRIC ASSOCIATION
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Dates
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Enumeration Date | 05/24/2007
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Last Update Date | 10/17/2007
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Provider Practice Location Address
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Address Line | 775 SINSINAWA AVE
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City | EAST DUBUQUE
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State | IL
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Zip | 61025-1409
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Country | US
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Telephone | 563-872-5975
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Fax | 563-872-3248
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Provider Business Mailing Address
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Address Line | 775 SINSINAWA AVE
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City | EAST DUBUQUE
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State | IL
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Zip | 61025-1409
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Country | US
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Telephone | 563-872-5975
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Fax | 563-872-3248
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Authorized Official
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Title or Position | OPTOMETRIST
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Name | STEVEN DONALD SLOAN
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Credential | OD
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Telephone | 563-872-5975
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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 | 0046007595
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License Number State | IL
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