Provider Demographics
NPI:1447373378
Name:LEBANON OPTOMETRIC CENTER, LLC
Entity type:Organization
Organization Name:LEBANON OPTOMETRIC CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:THORPE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:618-537-6356
Mailing Address - Street 1:201 W SAINT LOUIS ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:IL
Mailing Address - Zip Code:62254-1515
Mailing Address - Country:US
Mailing Address - Phone:618-537-6356
Mailing Address - Fax:618-537-6358
Practice Address - Street 1:201 W SAINT LOUIS ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:IL
Practice Address - Zip Code:62254-1515
Practice Address - Country:US
Practice Address - Phone:618-537-6356
Practice Address - Fax:618-537-6358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-07
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046007516152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0266170001Medicare NSC
IL410011581Medicare PIN
IL689710Medicare Oscar/Certification
IL410011580Medicare PIN