Provider Demographics
NPI:1679742183
Name:ILLINOIS EXPRESS VISION CENTER, MATTOON INC
Entity Type:Organization
Organization Name:ILLINOIS EXPRESS VISION CENTER, MATTOON INC
Other - Org Name:MT VERNON EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-235-1100
Mailing Address - Street 1:420 BROADWAY AVE E
Mailing Address - Street 2:
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938-4604
Mailing Address - Country:US
Mailing Address - Phone:217-235-1100
Mailing Address - Fax:217-235-1126
Practice Address - Street 1:3917 BROADWAY ST
Practice Address - Street 2:TIMES SQUARE MALL
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-2290
Practice Address - Country:US
Practice Address - Phone:618-244-5522
Practice Address - Fax:618-244-9512
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-28
Last Update Date:2016-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL371279746001Medicaid