Provider Demographics
NPI:1700286143
Name:PONTIAC FAMILY EYE CARE LLC
Entity Type:Organization
Organization Name:PONTIAC FAMILY EYE CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:STOLLER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:815-842-4304
Mailing Address - Street 1:320 N LADD ST
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:IL
Mailing Address - Zip Code:61764-1612
Mailing Address - Country:US
Mailing Address - Phone:815-843-4304
Mailing Address - Fax:815-844-5495
Practice Address - Street 1:320 N LADD ST
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:IL
Practice Address - Zip Code:61764-1612
Practice Address - Country:US
Practice Address - Phone:815-842-4304
Practice Address - Fax:815-844-5495
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HORIZON VISION GROUP SOLE MBR
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-09-03
Last Update Date:2014-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty