=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396940938
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARENGO VISION CENTER, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2007
-----------------------------------------------------
Last Update Date | 04/18/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 313 N DIVISION ST
-----------------------------------------------------
City | HARVARD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60033-3060
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-943-6635
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 313 N DIVISION ST
-----------------------------------------------------
City | HARVARD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60033-3060
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-943-6635
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MICHAEL W. THOMAS
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 815-568-6508
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 046-009334
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------