Provider Demographics
NPI:1649307547
Name:FAMILY EYE CARE OF ALGONQUIN, LTD.
Entity type:Organization
Organization Name:FAMILY EYE CARE OF ALGONQUIN, LTD.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:DIXON
Authorized Official - Last Name:HEINKE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:815-338-0674
Mailing Address - Street 1:233 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:IL
Mailing Address - Zip Code:60098-3399
Mailing Address - Country:US
Mailing Address - Phone:815-338-0674
Mailing Address - Fax:815-338-6139
Practice Address - Street 1:233 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:IL
Practice Address - Zip Code:60098-3399
Practice Address - Country:US
Practice Address - Phone:815-338-0674
Practice Address - Fax:815-338-6139
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2009-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046009519152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046009519Medicaid
=========OtherEIN
=========OtherEIN
IL046009519Medicaid