Provider Demographics
NPI:1396046090
Name:MERVI H LEYENDECKERS, O.D., P.C.
Entity Type:Organization
Organization Name:MERVI H LEYENDECKERS, O.D., P.C.
Other - Org Name:BROADWAY VISION CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MERVI
Authorized Official - Middle Name:H
Authorized Official - Last Name:LEYENDECKERS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:217-222-6888
Mailing Address - Street 1:926 BROADWAY STREET
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-2730
Mailing Address - Country:US
Mailing Address - Phone:217-222-6888
Mailing Address - Fax:217-222-6975
Practice Address - Street 1:926 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-2730
Practice Address - Country:US
Practice Address - Phone:217-222-6888
Practice Address - Fax:217-222-6975
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-11
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046008462152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU33391Medicare UPIN