=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336246552
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHITTICK FAMILY EYE CARE LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2006
-----------------------------------------------------
Last Update Date | 11/19/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1104 N VERMILION ST
-----------------------------------------------------
City | DANVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61832-3094
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-398-2020
-----------------------------------------------------
Fax | 217-442-0119
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1104 N VERMILION ST
-----------------------------------------------------
City | DANVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61832-3094
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-398-2020
-----------------------------------------------------
Fax | 217-442-0119
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. SHAWN P MALLADY
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 508-837-3790
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207WX0009X
-----------------------------------------------------
Taxonomy Name | Glaucoma Specialist (Ophthalmology) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------