Provider Demographics
NPI:1346406337
Name:LEON OPTOMETRIC CLINIC PC
Entity Type:Organization
Organization Name:LEON OPTOMETRIC CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:LEON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:217-832-2111
Mailing Address - Street 1:10 W ADAMS AVE
Mailing Address - Street 2:
Mailing Address - City:VILLA GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:61956-1513
Mailing Address - Country:US
Mailing Address - Phone:217-832-2111
Mailing Address - Fax:217-832-9935
Practice Address - Street 1:10 W ADAMS AVE # 200
Practice Address - Street 2:
Practice Address - City:VILLA GROVE
Practice Address - State:IL
Practice Address - Zip Code:61956-1513
Practice Address - Country:US
Practice Address - Phone:217-832-2111
Practice Address - Fax:217-832-9935
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-30
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046007325152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6195601Medicaid
IL6195601Medicaid
0861290001Medicare NSC
ILT38099Medicare UPIN