| |
103 Clintonian Plaza, Breese, IL 62230 | |
(636) 200-4393 | |
(618) 526-7455 |
Full Name | |
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Type | Facility |
Speciality | Optometrist |
Location | 103 Clintonian Plaza, Breese, Illinois |
Accepts Medicare Assignments | Does not participate in Medicare Program. The facility may not accept medicare assignment. |
Identifier | Type | State | Issuer |
---|---|---|---|
1063606978 | NPI | - | NPPES |
036104178 | Medicaid | IL |
Taxonomy | Type | License (State) | Status |
---|---|---|---|
152W00000X | Optometrist | 036104178 (Illinois) | Primary |
Mailing Address | Practice Location Address |
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Po Box 207163, Dallas, TX 75320-7154 Ph: (636) 200-4393 | 103 Clintonian Plaza, Breese, IL 62230 Ph: (636) 200-4393 |