Provider Demographics
NPI:1336605344
Name:PALISADES OPTOMETRICS LLC
Entity Type:Organization
Organization Name:PALISADES OPTOMETRICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TARA
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-322-6892
Mailing Address - Street 1:112 E WASHINGTON ST STE 1100
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-1001
Mailing Address - Country:US
Mailing Address - Phone:092-228-2753
Mailing Address - Fax:
Practice Address - Street 1:348 BROAD AVE
Practice Address - Street 2:
Practice Address - City:LEONIA
Practice Address - State:NJ
Practice Address - Zip Code:07605-1703
Practice Address - Country:US
Practice Address - Phone:201-429-9762
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-14
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty