Provider Demographics
NPI:1447420518
Name:ILLINI EYECARE INC-CHAMPAIGN
Entity Type:Organization
Organization Name:ILLINI EYECARE INC-CHAMPAIGN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:ALICE
Authorized Official - Last Name:SANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:217-351-6110
Mailing Address - Street 1:518 E GREEN ST
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-5720
Mailing Address - Country:US
Mailing Address - Phone:217-351-6110
Mailing Address - Fax:217-351-6395
Practice Address - Street 1:518 E GREEN ST
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-5720
Practice Address - Country:US
Practice Address - Phone:217-351-6110
Practice Address - Fax:217-351-6395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-05
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046009770152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty