Provider Demographics
NPI:1114095312
Name:HEITZ OPTICAL INC
Entity Type:Organization
Organization Name:HEITZ OPTICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DREW
Authorized Official - Middle Name:
Authorized Official - Last Name:RINACKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-465-1712
Mailing Address - Street 1:2415 HOMER M ADAMS PKWY
Mailing Address - Street 2:P.O. BOX 598
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-5615
Mailing Address - Country:US
Mailing Address - Phone:618-465-1712
Mailing Address - Fax:618-465-3114
Practice Address - Street 1:2415 HOMER M ADAMS PKWY
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-5615
Practice Address - Country:US
Practice Address - Phone:618-465-1712
Practice Address - Fax:618-465-3114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1645-6246156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0268620001Medicare ID - Type Unspecified