Provider Demographics
NPI:1952468993
Name:GRANITE CITY EYE CARE, INC.
Entity Type:Organization
Organization Name:GRANITE CITY EYE CARE, INC.
Other - Org Name:PEARLE VISION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:COX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-876-2438
Mailing Address - Street 1:3717 NAMEOKI RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:GRANITE CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62040-3720
Mailing Address - Country:US
Mailing Address - Phone:618-876-2438
Mailing Address - Fax:618-876-2440
Practice Address - Street 1:3717 NAMEOKI RD
Practice Address - Street 2:SUITE B
Practice Address - City:GRANITE CITY
Practice Address - State:IL
Practice Address - Zip Code:62040-3720
Practice Address - Country:US
Practice Address - Phone:618-876-2438
Practice Address - Fax:618-876-2440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No156FC0801XEye and Vision Services ProvidersTechnician/TechnologistContact Lens FitterGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL214954Medicare PIN
IL5911760001Medicare NSC