Provider Demographics
NPI:1669656252
Name:TAYLORVILLE VISION CENTER, LTD
Entity Type:Organization
Organization Name:TAYLORVILLE VISION CENTER, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:W
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:217-287-2020
Mailing Address - Street 1:108 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TAYLORVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62568-2230
Mailing Address - Country:US
Mailing Address - Phone:217-287-2020
Mailing Address - Fax:217-824-2228
Practice Address - Street 1:108 S MAIN ST
Practice Address - Street 2:
Practice Address - City:TAYLORVILLE
Practice Address - State:IL
Practice Address - Zip Code:62568-2230
Practice Address - Country:US
Practice Address - Phone:217-287-2020
Practice Address - Fax:217-824-2228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-19
Last Update Date:2009-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL060009009152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL993490Medicare PIN
ILU28335Medicare UPIN
IL5415400002Medicare NSC
IL216355Medicare PIN