Provider Demographics
NPI:1053400473
Name:FAMILY EYE CARE ASSOCIATION, P.C.
Entity type:Organization
Organization Name:FAMILY EYE CARE ASSOCIATION, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:W
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:618-664-0636
Mailing Address - Street 1:101 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62246-1734
Mailing Address - Country:US
Mailing Address - Phone:618-664-0636
Mailing Address - Fax:618-664-2749
Practice Address - Street 1:101 W MAIN ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:IL
Practice Address - Zip Code:62246-1734
Practice Address - Country:US
Practice Address - Phone:618-664-0636
Practice Address - Fax:618-664-2749
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2013-02-27
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
IL0474650002Medicare NSC