MEDICARE: INNOVATIVE EYE CARE SOLUTIONS, LTD.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	6009155	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	211358	OTHER	IL	MEDICARE GROUP

General Provider Information

NPI Number	:	1811088404
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INNOVATIVE EYE CARE SOLUTIONS, LTD.

Provider Business Mailing Address
First Line	:	22 N JACKSON ST
Second Line	:
City	:	BELLEVILLE
State	:	IL
Zip	:	62220-1425
Country	:	US
Telephone Number	:	618-233-1270
Fax Number	:

Provider Business Practice Location Address
First Line	:	22 N JACKSON ST
Second Line	:
City	:	BELLEVILLE
State	:	IL
Zip	:	62220-1425
Country	:	US
Telephone Number	:	618-233-1270
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. WILLIAM VERNON RITZEL
Credential	:	O.D.
Telephone Number	:	618-233-1270

Provider Enumeration Date	:	09/27/2006
Last Update Date	:	11/10/2010

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