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General NPI Number Information
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NPI Number | 1942862214
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Entity Type | Organization
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Legal Business Name | HAVERA EYE CARE SPECIALISTS LLC
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Dates
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Enumeration Date | 07/08/2019
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Last Update Date | 07/08/2019
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Provider Practice Location Address
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Address Line | 119 N MORRISON AVE
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City | COLLINSVILLE
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State | IL
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Zip | 62234-3226
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Country | US
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Telephone | 618-344-0511
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Fax | 618-344-0545
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Provider Business Mailing Address
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Address Line | 2701 FIELDSTONE DR
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City | MARYVILLE
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State | IL
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Zip | 62062-6436
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Country | US
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Telephone | 217-259-9023
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Fax |
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Authorized Official
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Title or Position | OPTOMETRIST
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Name | DR. MARK A HAVERA
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Credential | O.D.
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Telephone | 618-344-0511
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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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