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General NPI Number Information
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NPI Number | 1437193554
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Entity Type | Organization
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Legal Business Name | EIGENBRODT VISION CENTER, P.C.
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Dates
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Enumeration Date | 06/16/2006
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Last Update Date | 06/04/2009
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Provider Practice Location Address
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Address Line | 1950 EDWARDSVILLE CLUB PLAZA
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City | EDWARDSVILLE
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State | IL
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Zip | 62025-3717
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Country | US
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Telephone | 618-656-3199
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Fax | 618-656-3099
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Provider Business Mailing Address
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Address Line | 1950 EDWARDSVILLE CLUB PLAZA CT
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City | EDWARDSVILLE
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State | IL
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Zip | 62025-3717
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Country | US
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Telephone | 618-656-3199
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Fax | 618-656-3099
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JOHN ROBERT EIGENBRODT
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Credential | O.D.
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Telephone | 618-656-3199
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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 | 046008144
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License Number State | IL
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