Provider Demographics
NPI:1104081587
Name:WENDY'S EYEGLASS SHACK, INC.
Entity type:Organization
Organization Name:WENDY'S EYEGLASS SHACK, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CERTIFIED OPTICIAN
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:RUTH
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-693-0100
Mailing Address - Street 1:8424 N KNOXVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-2032
Mailing Address - Country:US
Mailing Address - Phone:309-693-0100
Mailing Address - Fax:
Practice Address - Street 1:8424 N KNOXVILLE AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-2032
Practice Address - Country:US
Practice Address - Phone:309-693-0100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-24
Last Update Date:2010-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL136295156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6433290001Medicare NSC