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General NPI Number Information
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NPI Number | 1639166226
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Entity Type | Individual
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Provider Name | KENNETH A SCHAIDLE O.D.
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Gender | Male
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Dates
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Enumeration Date | 09/29/2005
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Last Update Date | 01/10/2014
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Provider Practice Location Address
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Address Line | 4620 N UNIVERSITY ST
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City | PEORIA
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State | IL
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Zip | 61614-5889
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Country | US
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Telephone | 309-692-8222
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Fax | 309-692-8226
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Provider Business Mailing Address
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Address Line | 8309 N KNOXVILLE AVE
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City | PEORIA
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State | IL
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Zip | 61615-2170
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Country | US
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Telephone | 309-693-9540
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Fax | 309-693-9542
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | 046008408
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License Number State | IL
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