Provider Demographics
NPI:1326366618
Name:FITCH ENTERPRISES OF PEORIA, LLC
Entity Type:Organization
Organization Name:FITCH ENTERPRISES OF PEORIA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:W
Authorized Official - Last Name:FITCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-691-4500
Mailing Address - Street 1:608 W THOUSAND OAKS DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-1396
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4900 N GLEN PARK PLACE RD
Practice Address - Street 2:SUITE C2
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-4679
Practice Address - Country:US
Practice Address - Phone:309-691-4500
Practice Address - Fax:309-693-2536
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-11
Last Update Date:2010-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046006836152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Single Specialty