Provider Demographics
NPI:1477614329
Name:EYESITE-ILLINOIS VALLEY, LLC
Entity Type:Organization
Organization Name:EYESITE-ILLINOIS VALLEY, LLC
Other - Org Name:ILLINOIS VALLEY EYE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENT
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:KUNKEL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:815-664-5331
Mailing Address - Street 1:215 RICHARD A MAUTINO DR
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:IL
Mailing Address - Zip Code:61362-1144
Mailing Address - Country:US
Mailing Address - Phone:815-664-5331
Mailing Address - Fax:815-663-5057
Practice Address - Street 1:215 RICHARD A MAUTINO DR
Practice Address - Street 2:
Practice Address - City:SPRING VALLEY
Practice Address - State:IL
Practice Address - Zip Code:61362-1144
Practice Address - Country:US
Practice Address - Phone:815-664-5331
Practice Address - Fax:815-663-5057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-008411152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCK5289Medicare PIN
IL203365Medicare PIN
IL4592230001Medicare NSC