Provider Demographics
NPI:1801926340
Name:FAMILY EYE CARE OF OFALLON PC
Entity type:Organization
Organization Name:FAMILY EYE CARE OF OFALLON PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:D
Authorized Official - Last Name:ERNST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-532-1082
Mailing Address - Street 1:735 INSIGHT AVE
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-2193
Mailing Address - Country:US
Mailing Address - Phone:618-628-2903
Mailing Address - Fax:618-628-2913
Practice Address - Street 1:735 INSIGHT AVE
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-2193
Practice Address - Country:US
Practice Address - Phone:618-628-2903
Practice Address - Fax:618-628-2913
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046008375152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4714610001Medicare NSC