MEDICARE: MARENGO VISION CENTER, P.C.

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	060009322	IL

General Provider Information

NPI Number	:	1992736276
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARENGO VISION CENTER, P.C.

Provider Business Mailing Address
First Line	:	205 N STATE ST
Second Line	:
City	:	MARENGO
State	:	IL
Zip	:	60152-2239
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	205 N STATE ST
Second Line	:
City	:	MARENGO
State	:	IL
Zip	:	60152-2239
Country	:	US
Telephone Number	:	815-568-6508
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MICHAEL W. THOMAS
Credential	:
Telephone Number	:	815-568-6508

Provider Enumeration Date	:	07/05/2006
Last Update Date	:	08/23/2010

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