Provider Demographics
NPI:1497925754
Name:OPTOMETRIC CENTER, PC
Entity Type:Organization
Organization Name:OPTOMETRIC CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:815-273-2422
Mailing Address - Street 1:413 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SAVANNA
Mailing Address - State:IL
Mailing Address - Zip Code:61074-1535
Mailing Address - Country:US
Mailing Address - Phone:815-273-2422
Mailing Address - Fax:815-273-5034
Practice Address - Street 1:413 MAIN ST
Practice Address - Street 2:
Practice Address - City:SAVANNA
Practice Address - State:IL
Practice Address - Zip Code:61074-1964
Practice Address - Country:US
Practice Address - Phone:815-273-2422
Practice Address - Fax:815-273-5034
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-03
Last Update Date:2009-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046007403152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL210240Medicare PIN
IL0158100002Medicare NSC