Provider Demographics
NPI:1760405047
Name:INTERNATIONAL EYECARE CENTER LLC
Entity Type:Organization
Organization Name:INTERNATIONAL EYECARE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR. DIRECTOR, MVC/RCM
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:K
Authorized Official - Last Name:ALLISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-462-9818
Mailing Address - Street 1:111 E 4TH ST STE 440
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-6241
Mailing Address - Country:US
Mailing Address - Phone:618-604-5208
Mailing Address - Fax:
Practice Address - Street 1:2445 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-3257
Practice Address - Country:US
Practice Address - Phone:217-222-9207
Practice Address - Fax:217-641-0028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-26
Last Update Date:2022-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO530654904Medicaid
MO530654904Medicaid
IL392560Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER
MO990001397Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER