Provider Demographics
NPI:1073909354
Name:GENESEO VISION CENTER LLC
Entity Type:Organization
Organization Name:GENESEO VISION CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:309-944-5303
Mailing Address - Street 1:112 S CENTER ST
Mailing Address - Street 2:
Mailing Address - City:GENESEO
Mailing Address - State:IL
Mailing Address - Zip Code:61254-1338
Mailing Address - Country:US
Mailing Address - Phone:309-944-5303
Mailing Address - Fax:309-944-3465
Practice Address - Street 1:112 S CENTER ST
Practice Address - Street 2:
Practice Address - City:GENESEO
Practice Address - State:IL
Practice Address - Zip Code:61254-1338
Practice Address - Country:US
Practice Address - Phone:309-944-5303
Practice Address - Fax:309-944-3465
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-13
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL04600798152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046007958Medicaid
IL046007958Medicaid
ILT39043Medicare UPIN