Provider Demographics
NPI:1659506400
Name:BOURN AND ASSOCIATES, P.C.
Entity Type:Organization
Organization Name:BOURN AND ASSOCIATES, P.C.
Other - Org Name:BOURN VISION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:TONYA
Authorized Official - Middle Name:K
Authorized Official - Last Name:BOURN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:217-303-8600
Mailing Address - Street 1:64 NAVAJO DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62711-6084
Mailing Address - Country:US
Mailing Address - Phone:217-741-2315
Mailing Address - Fax:
Practice Address - Street 1:4000 WESTGATE DR STE B
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62711-7066
Practice Address - Country:US
Practice Address - Phone:217-303-8600
Practice Address - Fax:217-303-5950
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-22
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-008999152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1851340152Medicaid
IL1851340152Medicaid