Basic Information
| Provider Information | |||||||||
| NPI: | 1811224710 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EYECARE MANAGEMENT, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | ILLINOIS EYE SURGEONS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3990 N ILLINOIS ST | ||||||||
| Address2: | |||||||||
| City: | SWANSEA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622261919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182771130 | ||||||||
| FaxNumber: | 6182774917 | ||||||||
| Practice Location | |||||||||
| Address1: | 415 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | COLLINSVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622343043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6183457887 | ||||||||
| FaxNumber: | 6182774917 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2009 | ||||||||
| LastUpdateDate: | 05/09/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PELAEZ | ||||||||
| AuthorizedOfficialFirstName: | MISTY | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PR | ||||||||
| AuthorizedOfficialTelephone: | 6185321082 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 046006474 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.