Provider Demographics
NPI:1821228040
Name:PRAIRIE EYE CENTER LTD
Entity Type:Organization
Organization Name:PRAIRIE EYE CENTER LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:LANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-698-3030
Mailing Address - Street 1:130 W CENTER ST
Mailing Address - Street 2:
Mailing Address - City:GIRARD
Mailing Address - State:IL
Mailing Address - Zip Code:62640-1222
Mailing Address - Country:US
Mailing Address - Phone:217-627-2718
Mailing Address - Fax:217-627-3312
Practice Address - Street 1:130 W CENTER ST
Practice Address - Street 2:
Practice Address - City:GIRARD
Practice Address - State:IL
Practice Address - Zip Code:62640-1222
Practice Address - Country:US
Practice Address - Phone:217-627-2718
Practice Address - Fax:217-627-3312
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRAIRIE EYE CENTER, LTD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-07-22
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042000760152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL042000760OtherDEPARTMENT OF FINANCIAL AND PROFESSIONAL REGULATION
IN0364520004Medicare NSC