Provider Demographics
NPI:1710042643
Name:ALLIANCE EYECARE, INC.
Entity Type:Organization
Organization Name:ALLIANCE EYECARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT COMPTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:A
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-828-7723
Mailing Address - Street 1:1228 TOWANDA AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-3469
Mailing Address - Country:US
Mailing Address - Phone:309-828-7723
Mailing Address - Fax:
Practice Address - Street 1:1228 TOWANDA AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-3469
Practice Address - Country:US
Practice Address - Phone:309-828-7723
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-22
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
4718410001OtherDMERC
IL05732032OtherBLUE CROSS BLUE SHIELD