Provider Demographics
NPI:1265527394
Name:PERFORMANCE EYECARE PC
Entity type:Organization
Organization Name:PERFORMANCE EYECARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DIRK
Authorized Official - Middle Name:F
Authorized Official - Last Name:MASSIE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:618-234-3053
Mailing Address - Street 1:4111 N ILLINOIS ST
Mailing Address - Street 2:
Mailing Address - City:SWANSEA
Mailing Address - State:IL
Mailing Address - Zip Code:62226-7609
Mailing Address - Country:US
Mailing Address - Phone:618-234-3053
Mailing Address - Fax:618-234-6331
Practice Address - Street 1:4111 N ILLINOIS ST
Practice Address - Street 2:
Practice Address - City:SWANSEA
Practice Address - State:IL
Practice Address - Zip Code:62226-7609
Practice Address - Country:US
Practice Address - Phone:618-234-3053
Practice Address - Fax:618-234-6331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL469417152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL212342Medicare ID - Type UnspecifiedMEDICARE NUMBER