Provider Demographics
NPI:1043324361
Name:VISION CENTER OF LOVES PARK, INC.
Entity Type:Organization
Organization Name:VISION CENTER OF LOVES PARK, INC.
Other - Org Name:NEWCOMB EYE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:S
Authorized Official - Last Name:NEWCOMB
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:815-623-6060
Mailing Address - Street 1:11710 MAIN ST
Mailing Address - Street 2:SUITE #2
Mailing Address - City:ROSCOE
Mailing Address - State:IL
Mailing Address - Zip Code:61073-9566
Mailing Address - Country:US
Mailing Address - Phone:815-623-6060
Mailing Address - Fax:
Practice Address - Street 1:11710 MAIN ST
Practice Address - Street 2:SUITE # 2
Practice Address - City:ROSCOE
Practice Address - State:IL
Practice Address - Zip Code:61073-9566
Practice Address - Country:US
Practice Address - Phone:815-623-6060
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-17
Last Update Date:2009-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL346002079152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL10184028OtherBCBS
IL31795OtherDAVIS VISION INS.
IL=========-147201OtherNVA- ID# AND PIN #
IL=========-147201OtherNVA- ID# AND PIN #
IL760370Medicare ID - Type UnspecifiedPROVIDER #