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General NPI Number Information
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NPI Number | 1679742183
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Entity Type | Organization
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Legal Business Name | ILLINOIS EXPRESS VISION CENTER, MATTOON INC
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Dates
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Enumeration Date | 02/28/2008
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Last Update Date | 03/23/2016
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Provider Practice Location Address
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Address Line | 3917 BROADWAY ST TIMES SQUARE MALL
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City | MOUNT VERNON
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State | IL
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Zip | 62864-2290
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Country | US
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Telephone | 618-244-5522
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Fax | 618-244-9512
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Provider Business Mailing Address
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Address Line | 420 BROADWAY AVE E
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City | MATTOON
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State | IL
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Zip | 61938-4604
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Country | US
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Telephone | 217-235-1100
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Fax | 217-235-1126
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Authorized Official
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Title or Position | ASSISTANT MANAGER
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Name | AMY MARIE MILLER
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Credential |
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Telephone | 217-235-1100
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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 |
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License Number State |
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