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General NPI Number Information
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NPI Number | 1508163148
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Entity Type | Organization
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Legal Business Name | ROBERT M QUILLEASH OD PC
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Dates
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Enumeration Date | 02/17/2011
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Last Update Date | 08/13/2012
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Provider Practice Location Address
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Address Line | 2200 W WAR MEMORIAL DR PEARLE VISION C/O ROBERT QUILLEASH, OD
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City | PEORIA
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State | IL
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Zip | 61613
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Country | US
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Telephone | 309-688-2161
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Fax |
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Provider Business Mailing Address
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Address Line | 2200 W WAR MEMORIAL DR PEAREL VISION C/O ROBERT QUILLEASH, OD
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City | PEORIA
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State | IL
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Zip | 61613
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Country | US
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Telephone | 309-688-2161
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | ROBERT QUILLEASH
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Credential | O.D.
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Telephone | 309-370-3059
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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 | 046009163
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License Number State | IL
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