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General NPI Number Information
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NPI Number | 1750726022
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Entity Type | Organization
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Legal Business Name | FISHER-GENTRY EYE CARE PC
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Dates
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Enumeration Date | 05/01/2013
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Last Update Date | 06/24/2013
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Provider Practice Location Address
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Address Line | 501 S LOCUST ST
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City | MANTENO
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State | IL
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Zip | 60950-1656
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Country | US
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Telephone | 815-468-2015
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Fax | 815-468-2013
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Provider Business Mailing Address
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Address Line | 501 S LOCUST ST
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City | MANTENO
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State | IL
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Zip | 60950-1656
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Country | US
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Telephone | 815-468-2015
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Fax | 815-468-2013
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Authorized Official
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Title or Position | OPTOMETRIST/OWNER
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Name | DR. EMILY MARY GENTRY
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Credential | O.D.
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Telephone | 815-545-0335
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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 | 046010407
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License Number State | IL
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