Provider Demographics
NPI:1467613737
Name:THE EYEGLASS SHOPPE
Entity Type:Organization
Organization Name:THE EYEGLASS SHOPPE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:P
Authorized Official - Last Name:COTAL
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:815-795-3007
Mailing Address - Street 1:502 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MARSEILLES
Mailing Address - State:IL
Mailing Address - Zip Code:61341-1419
Mailing Address - Country:US
Mailing Address - Phone:815-795-3007
Mailing Address - Fax:815-795-3008
Practice Address - Street 1:502 MAIN ST
Practice Address - Street 2:
Practice Address - City:MARSEILLES
Practice Address - State:IL
Practice Address - Zip Code:61341-1419
Practice Address - Country:US
Practice Address - Phone:815-795-3007
Practice Address - Fax:815-795-3008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-19
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5747770001Medicare NSC