Provider Demographics
NPI:1760508931
Name:ILLINOIS EXPRESS VISION CENTER-MATTOON INC.
Entity Type:Organization
Organization Name:ILLINOIS EXPRESS VISION CENTER-MATTOON INC.
Other - Org Name:ILLINOIS EXPRESS EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:H
Authorized Official - Last Name:LANE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
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:
Practice Address - Street 1:420 BROADWAY AVE E
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-4604
Practice Address - Country:US
Practice Address - Phone:217-235-1100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2013-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear Supplier
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL7319OtherEYEMED PROVIDER NUMBER
IL01523250OtherBLUECROSS BLUE SHIELD ID#
IL0983570001Medicare ID - Type UnspecifiedADMINASTAR FEDERAL ID#
IL01523250OtherBLUECROSS BLUE SHIELD ID#
IL410044786Medicare ID - Type UnspecifiedRAILROAD MEDICARE ID #