Provider Demographics
NPI:1669660932
Name:PARK HILLS OPTICAL CO
Entity Type:Organization
Organization Name:PARK HILLS OPTICAL CO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREASURER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:JAMES
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:815-235-8083
Mailing Address - Street 1:1110 S PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:61032-4659
Mailing Address - Country:US
Mailing Address - Phone:815-235-8083
Mailing Address - Fax:815-232-3117
Practice Address - Street 1:1110 S PARK BLVD
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-4659
Practice Address - Country:US
Practice Address - Phone:815-235-8083
Practice Address - Fax:815-232-3117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-11
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILIBT#1542-9199332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1285635722OtherNPI
IL1184682635OtherNPI
IL1437134509OtherNPI
0442650001OtherDMERC PROVIDER
IL1285635722OtherNPI
0442650001OtherDMERC PROVIDER
ILU66380Medicare UPIN
IL305970Medicare PIN
IL1184682635OtherNPI
ILU67136Medicare UPIN