Provider Demographics
NPI:1912137266
Name:FOUNTAINS EYECARE CENTER, PC
Entity Type:Organization
Organization Name:FOUNTAINS EYECARE CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:ERIC
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:618-622-3013
Mailing Address - Street 1:314 FOUNTAINS PKWY
Mailing Address - Street 2:SUITE D
Mailing Address - City:FAIRVIEW HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:62208-2165
Mailing Address - Country:US
Mailing Address - Phone:618-622-3013
Mailing Address - Fax:
Practice Address - Street 1:314 FOUNTAINS PKWY
Practice Address - Street 2:SUITE D
Practice Address - City:FAIRVIEW HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:62208-2165
Practice Address - Country:US
Practice Address - Phone:618-622-3013
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-21
Last Update Date:2010-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-008905152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6363710001Medicare NSC