Provider Demographics
NPI:1366424756
Name:PEORIA EYE CLINIC, LTD
Entity type:Organization
Organization Name:PEORIA EYE CLINIC, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:C
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-676-2020
Mailing Address - Street 1:2422 W NEBRASKA AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61604-3112
Mailing Address - Country:US
Mailing Address - Phone:309-676-2020
Mailing Address - Fax:309-673-2020
Practice Address - Street 1:2422 W NEBRASKA AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61604-3112
Practice Address - Country:US
Practice Address - Phone:309-676-2020
Practice Address - Fax:309-673-2020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL37103572OtherFEDERAL TAX ID NUMBER
IL37103572OtherFEDERAL TAX ID NUMBER