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General NPI Number Information
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NPI Number | 1568656023
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Entity Type | Organization
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Legal Business Name | ILLINI EYECARE MONTICELLO INC
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Dates
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Enumeration Date | 08/28/2007
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Last Update Date | 10/15/2009
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Provider Practice Location Address
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Address Line | 102 S CHARTER ST
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City | MONTICELLO
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State | IL
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Zip | 61856-1853
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Country | US
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Telephone | 217-762-2551
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Fax |
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Provider Business Mailing Address
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Address Line | 102 S CHARTER ST
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City | MONTICELLO
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State | IL
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Zip | 61856-1853
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Country | US
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Telephone | 217-762-2551
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Fax |
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MR. SHIRLEY ANN FISHER
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Credential |
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Telephone | 217-762-2551
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152WP0200X
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Taxonomy Name | Pediatric Optometrist
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License Number | 046007835
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 152WX0102X
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Taxonomy Name | Occupational Vision Optometrist
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License Number | 046007835
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License Number State | IL
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