Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | 046-007703 | IL |
N | 152WC0802X | Optomitrist - Corneal and Contact Lenses | 046-007703 | IL |
NPI | 1104899053 |
---|---|
Provider Name | John Everd Brothers |
First Address | Champaign, IL 61822-8537 |
Second Address | Danville, IL 61832-3094 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/02/2006 |
Last Update Date | 09/10/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
16361 | COLE MANAGED VISION (01) | IL |
216981 | PERSONAL CARE (01) | IL |
U33555 | (02) | IL |