Provider Demographics
NPI:1538151592
Name:FREEPORT OPTOMETRIC CENTER P C
Entity type:Organization
Organization Name:FREEPORT OPTOMETRIC CENTER P C
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LAVONNE
Authorized Official - Middle Name:M
Authorized Official - Last Name:DOOLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-235-3466
Mailing Address - Street 1:980 W SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:61032-6777
Mailing Address - Country:US
Mailing Address - Phone:815-235-3466
Mailing Address - Fax:815-235-1712
Practice Address - Street 1:980 W SOUTH ST
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-6777
Practice Address - Country:US
Practice Address - Phone:815-235-3466
Practice Address - Fax:815-235-1712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-16
Last Update Date:2023-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL46-7729152W00000X
IL46-8516152W00000X
IL46-6980152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL741820Medicare Oscar/Certification
IL741820Medicare PIN
IL0203850001Medicare NSC