Provider Demographics
NPI:1376789578
Name:OPTOMETRIC EYECARE, INC
Entity Type:Organization
Organization Name:OPTOMETRIC EYECARE, INC
Other - Org Name:OLNEY EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CLARK
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:DESHON
Authorized Official - Suffix:
Authorized Official - Credentials:OD, FAAO
Authorized Official - Phone:618-395-2676
Mailing Address - Street 1:303 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OLNEY
Mailing Address - State:IL
Mailing Address - Zip Code:62450-2117
Mailing Address - Country:US
Mailing Address - Phone:618-395-2676
Mailing Address - Fax:
Practice Address - Street 1:303 E MAIN ST
Practice Address - Street 2:
Practice Address - City:OLNEY
Practice Address - State:IL
Practice Address - Zip Code:62450
Practice Address - Country:US
Practice Address - Phone:618-395-2676
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OPTOMETRIC EYECARE, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-12-18
Last Update Date:2018-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-008793152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6299000002Medicare NSC