Provider Demographics
NPI:1891328530
Name:TALLIS OPTOMETRY, PLLC
Entity Type:Organization
Organization Name:TALLIS OPTOMETRY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAY
Authorized Official - Middle Name:EDWIN
Authorized Official - Last Name:TALLIS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:309-827-8434
Mailing Address - Street 1:915 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-3043
Mailing Address - Country:US
Mailing Address - Phone:309-827-8434
Mailing Address - Fax:309-828-6741
Practice Address - Street 1:915 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-3043
Practice Address - Country:US
Practice Address - Phone:309-827-8434
Practice Address - Fax:309-828-6741
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-21
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty