Provider Demographics
NPI:1588069744
Name:BOYD OPTOMETRIC INC
Entity type:Organization
Organization Name:BOYD OPTOMETRIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMISON
Authorized Official - Middle Name:T
Authorized Official - Last Name:BOYD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:217-728-4451
Mailing Address - Street 1:108 E HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:SULLIVAN
Mailing Address - State:IL
Mailing Address - Zip Code:61951-2002
Mailing Address - Country:US
Mailing Address - Phone:217-728-4451
Mailing Address - Fax:217-728-8958
Practice Address - Street 1:108 E HARRISON ST
Practice Address - Street 2:
Practice Address - City:SULLIVAN
Practice Address - State:IL
Practice Address - Zip Code:61951-2002
Practice Address - Country:US
Practice Address - Phone:217-728-4451
Practice Address - Fax:217-728-8958
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-30
Last Update Date:2014-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
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ILU58272Medicare UPIN
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