Basic Information
Provider Information | |||||||||
NPI: | 1730290347 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KIRK | ||||||||
FirstName: | KARLA | ||||||||
MiddleName: | YVETTE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | O.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 8309 N KNOXVILLE AVE | ||||||||
Address2: |   | ||||||||
City: | PEORIA | ||||||||
State: | IL | ||||||||
PostalCode: | 616152170 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3096939540 | ||||||||
FaxNumber: | 3096939542 | ||||||||
Practice Location | |||||||||
Address1: | 3215 E LINCOLNWAY | ||||||||
Address2: |   | ||||||||
City: | STERLING | ||||||||
State: | IL | ||||||||
PostalCode: | 610811772 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8156266006 | ||||||||
FaxNumber: | 8156266008 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/31/2006 | ||||||||
LastUpdateDate: | 01/09/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 046-007509 | IL | Y |   | Eye and Vision Services Providers | Optometrist |   |
No ID Information.