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General NPI Number Information
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NPI Number | 1578803011
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Entity Type | Organization
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Legal Business Name | EYECARE OF CARLINVILLE PC
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Dates
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Enumeration Date | 02/20/2013
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Last Update Date | 02/20/2013
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Provider Practice Location Address
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Address Line | 300 N BROAD ST
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City | CARLINVILLE
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State | IL
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Zip | 62626-1304
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Country | US
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Telephone | 217-854-7611
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Fax | 217-854-8120
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Provider Business Mailing Address
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Address Line | 300 N BROAD ST
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City | CARLINVILLE
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State | IL
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Zip | 62626-1304
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Country | US
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Telephone | 217-854-7611
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Fax | 217-854-8120
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Authorized Official
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Title or Position | OPTOMETRIST
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Name | DR. KATIE M GOODMAN-THOMAS
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Credential | OD
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Telephone | 217-854-7611
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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 | 046010516
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License Number State | IL
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