Basic Information
| Provider Information | |||||||||
| NPI: | 1316086580 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHULTZ | ||||||||
| FirstName: | SABRINA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2020 W ILES AVE | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627047015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2176983030 | ||||||||
| FaxNumber: | 2176984728 | ||||||||
| Practice Location | |||||||||
| Address1: | 18 GINGER CREEK PKWY | ||||||||
| Address2: | |||||||||
| City: | GLEN CARBON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620343502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6186567774 | ||||||||
| FaxNumber: | 6186560536 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2007 | ||||||||
| LastUpdateDate: | 05/20/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 046009802 | IL | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 046009802 | 05 | IL | MEDICAID |