Provider Demographics
NPI:1396753513
Name:ASSOCIATED OPTOMETRISTS, PC
Entity type:Organization
Organization Name:ASSOCIATED OPTOMETRISTS, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:NIELSEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:815-397-5337
Mailing Address - Street 1:1641 N ALPINE RD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-1458
Mailing Address - Country:US
Mailing Address - Phone:815-397-5337
Mailing Address - Fax:815-397-5540
Practice Address - Street 1:1641 N ALPINE RD
Practice Address - Street 2:SUITE 205
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-1458
Practice Address - Country:US
Practice Address - Phone:815-397-5337
Practice Address - Fax:815-397-5540
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
212809Medicare ID - Type Unspecified
T33504Medicare UPIN