Provider Demographics
NPI:1912209768
Name:FAMILY VISION THERAPY PC
Entity Type:Organization
Organization Name:FAMILY VISION THERAPY PC
Other - Org Name:FAMILY VISION DEVELOPMENT CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:630-862-2020
Mailing Address - Street 1:444 N EOLA RD
Mailing Address - Street 2:#105
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60502-9615
Mailing Address - Country:US
Mailing Address - Phone:630-862-2020
Mailing Address - Fax:630-862-2027
Practice Address - Street 1:444 N EOLA RD
Practice Address - Street 2:#105
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60502-9615
Practice Address - Country:US
Practice Address - Phone:630-862-2020
Practice Address - Fax:630-862-2027
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-30
Last Update Date:2011-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-009753152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL4373Medicare PIN