Provider Demographics
NPI:1891820312
Name:MAPLESHADE VISION CENTER INC.
Entity Type:Organization
Organization Name:MAPLESHADE VISION CENTER INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GAYLAN
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:MOUSHON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:309-243-5900
Mailing Address - Street 1:11825 STATE ROUTE 40
Mailing Address - Street 2:SUITE 101
Mailing Address - City:DUNLAP
Mailing Address - State:IL
Mailing Address - Zip Code:61525-8842
Mailing Address - Country:US
Mailing Address - Phone:309-243-5900
Mailing Address - Fax:309-243-9852
Practice Address - Street 1:11825 STATE ROUTE 40
Practice Address - Street 2:SUITE 101
Practice Address - City:DUNLAP
Practice Address - State:IL
Practice Address - Zip Code:61525-8842
Practice Address - Country:US
Practice Address - Phone:309-243-5900
Practice Address - Fax:309-243-9852
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2007-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0460088755152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty