Provider Demographics
NPI:1003816000
Name:FAMILY EYE CARE OF PONTIAC, LLC
Entity Type:Organization
Organization Name:FAMILY EYE CARE OF PONTIAC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:REID
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:PETTIT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:815-842-4304
Mailing Address - Street 1:320 N LADD ST
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:IL
Mailing Address - Zip Code:61764-1612
Mailing Address - Country:US
Mailing Address - Phone:815-842-4304
Mailing Address - Fax:815-844-5495
Practice Address - Street 1:320 N LADD ST
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:IL
Practice Address - Zip Code:61764-1612
Practice Address - Country:US
Practice Address - Phone:815-842-4304
Practice Address - Fax:815-844-5495
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
4991920001OtherDME
05332011OtherBLUE CROSS
DB0240OtherRAILROAD
4991920001OtherDME