Provider Demographics
NPI:1336265875
Name:CENTRAL ILLINOIS OPTOMETRIC ASSOCIATES LTD
Entity type:Organization
Organization Name:CENTRAL ILLINOIS OPTOMETRIC ASSOCIATES LTD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:HEDRICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-965-3306
Mailing Address - Street 1:119 N SPRINGFIELD ST
Mailing Address - Street 2:
Mailing Address - City:VIRDEN
Mailing Address - State:IL
Mailing Address - Zip Code:62690-1455
Mailing Address - Country:US
Mailing Address - Phone:217-965-3306
Mailing Address - Fax:217-965-3679
Practice Address - Street 1:119 N SPRINGFIELD ST
Practice Address - Street 2:
Practice Address - City:VIRDEN
Practice Address - State:IL
Practice Address - Zip Code:62690-1455
Practice Address - Country:US
Practice Address - Phone:217-965-3306
Practice Address - Fax:217-965-3679
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2011-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046008125152W00000X
IL046006408152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL410042503OtherHEDRICK RAILRAOD MEDICARE
IL046006408Medicaid
IL0001115000OtherBC BS GROUP NUMBER
IL046008125Medicaid
IL410042688OtherRUBRICH RAILRAOD MEDICARE
IL410042688OtherRUBRICH RAILRAOD MEDICARE
ILT35434Medicare UPIN
IL046006408Medicaid
ILL08475Medicare ID - Type UnspecifiedHEDRICK MEDICARE
ILT35435Medicare UPIN
ILL08476Medicare ID - Type UnspecifiedRUBRICH MEDICARE