Provider Demographics
NPI:1952541179
Name:OPTOMETRIC EYECARE, INC
Entity Type:Organization
Organization Name:OPTOMETRIC EYECARE, INC
Other - Org Name:MT. CARMEL EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CLARK
Authorized Official - Middle Name:E
Authorized Official - Last Name:DESHON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:618-263-3362
Mailing Address - Street 1:715 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT CARMEL
Mailing Address - State:IL
Mailing Address - Zip Code:62863-1454
Mailing Address - Country:US
Mailing Address - Phone:618-263-3362
Mailing Address - Fax:618-263-6001
Practice Address - Street 1:715 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:MOUNT CARMEL
Practice Address - State:IL
Practice Address - Zip Code:62863-1454
Practice Address - Country:US
Practice Address - Phone:618-263-3362
Practice Address - Fax:618-263-6001
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OPTOMETRIC EYECARE, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-02-27
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-008793152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046008793Medicaid
IL5290131OtherAETNA
IL09327152OtherBLUE CROSS BLUE SHIELD OF IL
1861482309OtherPALMETTO GBA - RAILROAD MEDICARE
1861482309OtherPALMETTO GBA - RAILROAD MEDICARE
ILU36374Medicare UPIN
IL6299000001Medicare NSC