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General NPI Number Information
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NPI Number | 1770856437
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Entity Type | Organization
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Legal Business Name | KERRY HEAD AND ASSOCIATES
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Dates
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Enumeration Date | 02/10/2012
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Last Update Date | 02/10/2012
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Provider Practice Location Address
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Address Line | 730 TENNEY ST WAL-MART VISION CENTER
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City | KEWANEE
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State | IL
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Zip | 61443-3702
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Country | US
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Telephone | 309-853-2302
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Fax | 309-853-3015
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Provider Business Mailing Address
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Address Line | 730 TENNEY ST WAL-MART VISION CENTER
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City | KEWANEE
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State | IL
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Zip | 61443-3702
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Country | US
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Telephone | 309-853-2302
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Fax | 309-853-3015
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Authorized Official
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Title or Position | OPTOMOTRIST
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Name | MR. KERRY H HEAD
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Credential | OD
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Telephone | 309-853-2302
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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 | 046008928
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License Number State | IL
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