Provider Demographics
NPI:1619092863
Name:PREMIER EYECARE CENTER PC
Entity Type:Organization
Organization Name:PREMIER EYECARE CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:L
Authorized Official - Last Name:TOAL
Authorized Official - Suffix:JR
Authorized Official - Credentials:OD
Authorized Official - Phone:618-939-4040
Mailing Address - Street 1:742 N MARKET ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:WATERLOO
Mailing Address - State:IL
Mailing Address - Zip Code:62298
Mailing Address - Country:US
Mailing Address - Phone:618-939-4040
Mailing Address - Fax:618-939-3903
Practice Address - Street 1:742 N MARKET ST
Practice Address - Street 2:SUITE A
Practice Address - City:WATERLOO
Practice Address - State:IL
Practice Address - Zip Code:62298
Practice Address - Country:US
Practice Address - Phone:618-939-4040
Practice Address - Fax:618-939-3903
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2018-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046008356152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL06732021OtherBLUE CROSS BLUE SHIELD
IL210427Medicare PIN