Provider Demographics
NPI:1437535101
Name:HOME TOWN OPTICAL LLC
Entity Type:Organization
Organization Name:HOME TOWN OPTICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:ERIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-938-4949
Mailing Address - Street 1:480 WYLIE DR
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-5405
Mailing Address - Country:US
Mailing Address - Phone:309-938-4949
Mailing Address - Fax:
Practice Address - Street 1:480 WYLIE DR
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-5405
Practice Address - Country:US
Practice Address - Phone:309-938-4949
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-05
Last Update Date:2015-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear Supplier
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty