Basic Information
| Provider Information | |||||||||
| NPI: | 1598712002 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BEREKETAB | ||||||||
| FirstName: | ELILTA | ||||||||
| MiddleName: | |||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 757 | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 617020757 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3098295311 | ||||||||
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| Practice Location | |||||||||
| Address1: | 123 N 8TH ST | ||||||||
| Address2: | |||||||||
| City: | WATSEKA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 609701443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3098295311 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2006 | ||||||||
| LastUpdateDate: | 12/22/2011 | ||||||||
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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 | 046-009523 | IL | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.