Provider Demographics
NPI:1053852020
Name:CENTRAL ILLINOIS FAMILY EYECARE LLC
Entity Type:Organization
Organization Name:CENTRAL ILLINOIS FAMILY EYECARE LLC
Other - Org Name:PEORIA EYE PROFESSIONALS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:M
Authorized Official - Last Name:BRTVA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:309-686-0763
Mailing Address - Street 1:7815 N KNOXVILLE AVE STE 1A
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-2022
Mailing Address - Country:US
Mailing Address - Phone:309-839-1614
Mailing Address - Fax:309-839-8874
Practice Address - Street 1:4203 N SHERIDAN RD
Practice Address - Street 2:STE A1-4
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-7170
Practice Address - Country:US
Practice Address - Phone:309-686-0763
Practice Address - Fax:309-685-8809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-10
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-007731152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty