Provider Demographics
NPI:1770856437
Name:KERRY HEAD AND ASSOCIATES
Entity Type:Organization
Organization Name:KERRY HEAD AND ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMOTRIST
Authorized Official - Prefix:MR
Authorized Official - First Name:KERRY
Authorized Official - Middle Name:H
Authorized Official - Last Name:HEAD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:309-853-2302
Mailing Address - Street 1:730 TENNEY ST
Mailing Address - Street 2:WAL-MART VISION CENTER
Mailing Address - City:KEWANEE
Mailing Address - State:IL
Mailing Address - Zip Code:61443-3702
Mailing Address - Country:US
Mailing Address - Phone:309-853-2302
Mailing Address - Fax:309-853-3015
Practice Address - Street 1:730 TENNEY ST
Practice Address - Street 2:WAL-MART VISION CENTER
Practice Address - City:KEWANEE
Practice Address - State:IL
Practice Address - Zip Code:61443-3702
Practice Address - Country:US
Practice Address - Phone:309-853-2302
Practice Address - Fax:309-853-3015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-10
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046008928152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046008928Medicaid