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General NPI Number Information
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NPI Number | 1447420518
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Entity Type | Organization
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Legal Business Name | ILLINI EYECARE INC-CHAMPAIGN
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Dates
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Enumeration Date | 03/05/2008
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Last Update Date | 03/05/2008
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Provider Practice Location Address
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Address Line | 518 E GREEN ST
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City | CHAMPAIGN
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State | IL
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Zip | 61820-5720
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Country | US
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Telephone | 217-351-6110
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Fax | 217-351-6395
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Provider Business Mailing Address
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Address Line | 518 E GREEN ST
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City | CHAMPAIGN
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State | IL
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Zip | 61820-5720
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Country | US
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Telephone | 217-351-6110
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Fax | 217-351-6395
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Authorized Official
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Title or Position | OPTOMETRIST
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Name | DR. KELLY ALICE SANDERS
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Credential | OD
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Telephone | 217-351-6110
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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 | 046009770
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License Number State | IL
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