Provider Demographics
NPI:1154345551
Name:MIDWEST VISION CLINIC PLC
Entity type:Organization
Organization Name:MIDWEST VISION CLINIC PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:W
Authorized Official - Last Name:PECK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:815-589-2552
Mailing Address - Street 1:1130 17TH STREET
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:IL
Mailing Address - Zip Code:61252
Mailing Address - Country:US
Mailing Address - Phone:815-589-2252
Mailing Address - Fax:815-589-4201
Practice Address - Street 1:1130 17TH STREET
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:IL
Practice Address - Zip Code:61252
Practice Address - Country:US
Practice Address - Phone:815-589-2252
Practice Address - Fax:815-589-4201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty