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General NPI Number Information
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NPI Number | 1861860363
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Entity Type | Organization
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Legal Business Name | ALLIED VISION SOURCE, LLC
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Dates
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Enumeration Date | 09/14/2015
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Last Update Date | 03/25/2019
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Provider Practice Location Address
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Address Line | 2475 N MONROE ST
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City | DECATUR
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State | IL
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Zip | 62526-3941
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Country | US
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Telephone | 217-663-0118
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Fax |
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Provider Business Mailing Address
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Address Line | 2475 N MONROE ST
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City | DECATUR
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State | IL
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Zip | 62526-3941
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Country | US
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Telephone | 217-663-0118
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | ROBERT W JONES
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Credential | O.D.
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Telephone | 217-663-0118
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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 | 046.06977
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License Number State | IL
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