Provider Demographics
NPI:1144639105
Name:FAIRBURY VISION CENTER LLC
Entity type:Organization
Organization Name:FAIRBURY VISION CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:
Authorized Official - Last Name:GERBER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-692-2415
Mailing Address - Street 1:2 ASPEN CT
Mailing Address - Street 2:
Mailing Address - City:FAIRBURY
Mailing Address - State:IL
Mailing Address - Zip Code:61739-1487
Mailing Address - Country:US
Mailing Address - Phone:815-692-2415
Mailing Address - Fax:815-692-2675
Practice Address - Street 1:2 ASPEN CT
Practice Address - Street 2:
Practice Address - City:FAIRBURY
Practice Address - State:IL
Practice Address - Zip Code:61739-1487
Practice Address - Country:US
Practice Address - Phone:815-692-2415
Practice Address - Fax:815-692-2675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-04
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty