Provider Demographics
NPI:1790924884
Name:MT CARMEL EYECARE
Entity Type:Organization
Organization Name:MT CARMEL EYECARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-263-3362
Mailing Address - Street 1:715 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT CARMEL
Mailing Address - State:IL
Mailing Address - Zip Code:62863-1454
Mailing Address - Country:US
Mailing Address - Phone:618-263-3362
Mailing Address - Fax:618-263-6001
Practice Address - Street 1:715 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:MOUNT CARMEL
Practice Address - State:IL
Practice Address - Zip Code:62863-1454
Practice Address - Country:US
Practice Address - Phone:618-263-3362
Practice Address - Fax:618-263-6001
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OPTOMETRIC EYECARE INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-02-12
Last Update Date:2009-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046008793332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU36374Medicare UPIN