Basic Information
| Provider Information | |||||||||
| NPI: | 1346514031 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FUNKEYE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 N EAST ST | ||||||||
| Address2: | |||||||||
| City: | OLNEY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 624502432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6183955222 | ||||||||
| FaxNumber: | 6183958552 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 N EAST ST | ||||||||
| Address2: | |||||||||
| City: | OLNEY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 624502432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6183955222 | ||||||||
| FaxNumber: | 6183958552 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2012 | ||||||||
| LastUpdateDate: | 03/01/2012 | ||||||||
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| AuthorizedOfficialLastName: | FUNK | ||||||||
| AuthorizedOfficialFirstName: | TINA | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6183955222 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | O.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.