Provider Demographics
NPI:1164698148
Name:J.E. TALLIS DBA AMERICAN VISION CENTER
Entity Type:Organization
Organization Name:J.E. TALLIS DBA AMERICAN VISION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHRISANN
Authorized Official - Middle Name:
Authorized Official - Last Name:TALLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-827-8434
Mailing Address - Street 1:915 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-3043
Mailing Address - Country:US
Mailing Address - Phone:309-827-8434
Mailing Address - Fax:309-828-6741
Practice Address - Street 1:915 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-3043
Practice Address - Country:US
Practice Address - Phone:309-827-8434
Practice Address - Fax:309-828-6741
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-30
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046007271152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046007271Medicaid
IL934801OtherMEDICARE ID