Provider Demographics
NPI:1306057302
Name:TRI-STATE OPTOMETRIC ASSOCIATION
Entity type:Organization
Organization Name:TRI-STATE OPTOMETRIC ASSOCIATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:DONALD
Authorized Official - Last Name:SLOAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:563-872-5975
Mailing Address - Street 1:775 SINSINAWA AVE
Mailing Address - Street 2:
Mailing Address - City:EAST DUBUQUE
Mailing Address - State:IL
Mailing Address - Zip Code:61025-1409
Mailing Address - Country:US
Mailing Address - Phone:563-872-5975
Mailing Address - Fax:563-872-3248
Practice Address - Street 1:775 SINSINAWA AVE
Practice Address - Street 2:
Practice Address - City:EAST DUBUQUE
Practice Address - State:IL
Practice Address - Zip Code:61025-1409
Practice Address - Country:US
Practice Address - Phone:563-872-5975
Practice Address - Fax:563-872-3248
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0046007595152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL736340Medicare PIN