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General NPI Number Information
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NPI Number | 1851417513
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Entity Type | Organization
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Legal Business Name | CENTRAL ILLINOIS OPTOMETRIC ASSOCIATES LTD
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Dates
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Enumeration Date | 03/22/2007
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Last Update Date | 04/18/2011
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Provider Practice Location Address
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Address Line | 615 N BROAD ST
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City | CARLINVILLE
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State | IL
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Zip | 62626-1020
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Country | US
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Telephone | 217-854-3173
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Fax |
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Provider Business Mailing Address
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Address Line | 615 N BROAD ST
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City | CARLINVILLE
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State | IL
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Zip | 62626-1020
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Country | US
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Telephone | 217-854-3173
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | DR. KEITH HEDRICK
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Credential |
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Telephone | 217-854-3173
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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 | 046006408
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 046008125
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License Number State | IL
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