Basic Information
| Provider Information | |||||||||
| NPI: | 1194322131 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EAGAN EYE CLINIC LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 211 E BROADWAY | ||||||||
| Address2: | |||||||||
| City: | ALTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620026220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184629818 | ||||||||
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| Practice Location | |||||||||
| Address1: | 204 WASHBURNE AVE | ||||||||
| Address2: | |||||||||
| City: | PAYNESVILLE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563621643 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202046400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2020 | ||||||||
| LastUpdateDate: | 10/02/2020 | ||||||||
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| AuthorizedOfficialLastName: | CHUDNER | ||||||||
| AuthorizedOfficialFirstName: | BENJAMIN | ||||||||
| AuthorizedOfficialMiddleName: | S. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9723705552 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EAGAN EYE CLINIC LLC | ||||||||
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| AuthorizedOfficialCredential: | OD | ||||||||
| NPICertificationDate: | 10/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.