Provider Demographics
NPI:1841307329
Name:DE BOER OD., LTD
Entity type:Organization
Organization Name:DE BOER OD., LTD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:DE BOER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:219-987-3673
Mailing Address - Street 1:609 N HALLECK ST
Mailing Address - Street 2:
Mailing Address - City:DEMOTTE
Mailing Address - State:IN
Mailing Address - Zip Code:46310-9545
Mailing Address - Country:US
Mailing Address - Phone:219-987-3673
Mailing Address - Fax:219-987-3905
Practice Address - Street 1:609 N HALLECK ST
Practice Address - Street 2:
Practice Address - City:DEMOTTE
Practice Address - State:IN
Practice Address - Zip Code:46310-9545
Practice Address - Country:US
Practice Address - Phone:219-987-3673
Practice Address - Fax:219-987-3905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2024-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
152W00000X
IL046008335152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0176050001Medicare NSC
IL216094Medicare PIN
CF1117Medicare PIN