Basic Information
| Provider Information | |||||||||
| NPI: | 1366035644 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRAIRIE EYE CENTER, LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2020 W ILES AVE | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627044174 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2176983030 | ||||||||
| FaxNumber: | 2176983068 | ||||||||
| Practice Location | |||||||||
| Address1: | 518 BROADWAY ST | ||||||||
| Address2: | |||||||||
| City: | LINCOLN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 626562706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2177326062 | ||||||||
| FaxNumber: | 2177328495 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2021 | ||||||||
| LastUpdateDate: | 02/17/2021 | ||||||||
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| AuthorizedOfficialLastName: | LANG | ||||||||
| AuthorizedOfficialFirstName: | JASON | ||||||||
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| AuthorizedOfficialTitleorPosition: | BILLING ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2176983030 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PRAIRIE EYE CENTER, LTD | ||||||||
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| NPICertificationDate: | 02/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology | 152W00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.