=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336112804
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DENNIS M BRTVA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2006
-----------------------------------------------------
Last Update Date | 01/02/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 801 W LAKE AVE 300 EVERGREEN SQUARE
-----------------------------------------------------
City | PEORIA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61614-5951
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-686-0763
-----------------------------------------------------
Fax | 309-685-8809
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 801 W LAKE AVE 300 EVERGREEN SQUARE
-----------------------------------------------------
City | PEORIA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61614-5951
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-686-0763
-----------------------------------------------------
Fax | 309-685-8809
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. DENNIS M BRTVA
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 309-663-2211
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------