Basic Information
| Provider Information | |||||||||
| NPI: | 1215335385 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EYECARE MANAGEMENT, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | QUANTUM VISION CENTERS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3990 N ILLINOIS ST | ||||||||
| Address2: | |||||||||
| City: | SWANSEA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622261919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182771130 | ||||||||
| FaxNumber: | 6182774917 | ||||||||
| Practice Location | |||||||||
| Address1: | 4900 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BELLEVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622264725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182352400 | ||||||||
| FaxNumber: | 6182350900 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2014 | ||||||||
| LastUpdateDate: | 12/05/2014 | ||||||||
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| AuthorizedOfficialLastName: | JONES | ||||||||
| AuthorizedOfficialFirstName: | BART | ||||||||
| AuthorizedOfficialMiddleName: | AARON | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6185321082 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 036104178 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 036104178 | 01 | IL | LICENSE | OTHER |