Provider Demographics
NPI:1881135853
Name:CENTRAL ILLINOIS FAMILY EYECARE LLC
Entity type:Organization
Organization Name:CENTRAL ILLINOIS FAMILY EYECARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:M
Authorized Official - Last Name:BRTVA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:309-213-9200
Mailing Address - Street 1:1015 S MERCER AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-7107
Mailing Address - Country:US
Mailing Address - Phone:309-213-9200
Mailing Address - Fax:309-213-9300
Practice Address - Street 1:1015 S MERCER AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-7107
Practice Address - Country:US
Practice Address - Phone:309-213-9200
Practice Address - Fax:309-213-9300
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CENTRAL ILLINOIS FAMILY EYECARE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-03-10
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-007731152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty