Provider Demographics
NPI:1790865368
Name:FAMILY EYE CARE ASSOCIATION, P.C.
Entity Type:Organization
Organization Name:FAMILY EYE CARE ASSOCIATION, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:W
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:217-324-3317
Mailing Address - Street 1:510 W UNION AVE
Mailing Address - Street 2:
Mailing Address - City:LITCHFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62056-1937
Mailing Address - Country:US
Mailing Address - Phone:217-324-3317
Mailing Address - Fax:217-324-6833
Practice Address - Street 1:510 W UNION AVE
Practice Address - Street 2:
Practice Address - City:LITCHFIELD
Practice Address - State:IL
Practice Address - Zip Code:62056-1937
Practice Address - Country:US
Practice Address - Phone:217-324-3317
Practice Address - Fax:217-324-6833
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FAMILY EYE CARE ASSOCIATION, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-17
Last Update Date:2009-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046008093152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL214355Medicare PIN
IL0474650003Medicare NSC