Ava Rose Eyecare LTD
Organization Active NPI Optometrist · Galesburg, IL
NPI 1609258581 · NPPES record last updated Jun 26, 2015
Key facts
- NPI
- 1609258581
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Optometrist 152W00000X
- Legal business name
- AVA ROSE EYECARE LTD
- Practice address
- 1115 N Henderson St
Galesburg, IL 61401-2523 - Phone
- (309) 343-1107
- Fax
- (309) 343-1306
- NPI assigned
- Jun 26, 2015
- Organization subpart
- No
Authorized official
- Name
- Nathan C Dieckow, OD
- Title
- President
- Phone
- (314) 599-1034
Practitioners 2
-
Nathan Curtis Dieckow, O.D.
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in IL
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20150908000803 | IL | Part B Supplier - Clinic/Group Practice | 7416263413 |
Receives reassigned benefits from 1 practitioner Practice locations: Galesburg, IL |
National Provider Directory
Locations
1115 N Henderson St
Galesburg, IL 61401
Phone (309) 343-1107
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Optometrist |
152W00000X | Yes |
Addresses
Primary practice location
1115 N Henderson St
Galesburg, IL 61401-2523
Mailing address
1115 N Henderson St
Galesburg, IL 61401-2523
Phone (309) 343-1107
Other names
- Precision Family Eyecare
Other providers in Galesburg, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jun 26, 2015. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.