Provider Demographics
NPI:1881882504
Name:EYECARE ASSOCIATES, LLP
Entity type:Organization
Organization Name:EYECARE ASSOCIATES, LLP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:F
Authorized Official - Last Name:COUILLARD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:309-662-2277
Mailing Address - Street 1:2103 E. WASHINGTON
Mailing Address - Street 2:SUITE 1D
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-4358
Mailing Address - Country:US
Mailing Address - Phone:309-662-2277
Mailing Address - Fax:309-663-6472
Practice Address - Street 1:2103 E WASHINGTON ST STE 1D
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-4365
Practice Address - Country:US
Practice Address - Phone:309-662-2277
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-09
Last Update Date:2015-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046007251332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046007251Medicaid
IL0236740001Medicare NSC
IL217071Medicare PIN
IL046007251Medicaid