Geneseo Vision Center LLC

Primary specialty

OptometristTaxonomy code 152W00000X

License

04600798 Issued in IL

Legal business name

GENESEO VISION CENTER LLC

Practice address

112 S Center St
Geneseo, IL 61254-1338

Phone

(309) 944-5303

Fax

(309) 944-3465

NPI assigned

Apr 13, 2015

Organization subpart

No

Name

Ryan J Wilson, ODNPI 1407832454

Title

Owner

Phone

(309) 944-5303

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Ryan J Wilson, O.D.

  • Optometrist
  • Geneseo, IL
  • NPI 1407832454

  IL

  Medicare reassignment Authorized official

Medicare fee-for-service enrollment

Enrolled in IL

Enrollment records 1

Locations

The complete NPPES record for this NPI in the NPI Registry API format, last updated by the provider on Feb 16, 2024.

{
    "created_epoch": "1428883200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1708041600000",
    "number": "1073909354",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "112 S CENTER ST",
            "city": "GENESEO",
            "state": "IL",
            "postal_code": "612541338",
            "telephone_number": "309-944-5303",
            "fax_number": "309-944-3465"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "112 S CENTER ST",
            "city": "GENESEO",
            "state": "IL",
            "postal_code": "612541338",
            "telephone_number": "309-944-5303",
            "fax_number": "309-944-3465"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GENESEO VISION CENTER LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-04-13",
        "last_updated": "2024-02-16",
        "certification_date": "2024-02-16",
        "status": "A",
        "authorized_official_last_name": "WILSON",
        "authorized_official_first_name": "RYAN",
        "authorized_official_middle_name": "J",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "309-944-5303",
        "authorized_official_credential": "OD"
    },
    "taxonomies": [
        {
            "code": "152W00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Optometrist",
            "state": "IL",
            "license": "04600798",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "046007958",
            "state": "IL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Geneseo Fire Protection District
• Michelle Renae Goreth, PTA
• Kati Grimes, FNP-C
• Lokanatham Gumidyala
• John David Gustafson, RPH
• Alissa Haase

• All providers in Geneseo, IL
• Optometrist in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 16, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.