=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447448717
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FIRESIDE EYE CARE, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/11/2007
-----------------------------------------------------
Last Update Date | 01/16/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 600 S 8TH ST
-----------------------------------------------------
City | BENLD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62009-1446
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-835-7724
-----------------------------------------------------
Fax | 217-835-7611
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 600 S 8TH ST
-----------------------------------------------------
City | BENLD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62009-1446
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-835-7724
-----------------------------------------------------
Fax | 217-835-7611
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST
-----------------------------------------------------
Name | SHAWNA HEDDINGHAUS
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 217-835-7724
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 46009181
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------