Provider Demographics
NPI:1487724910
Name:ILLINOIS EXPRESS VIS CTR DNVLL INC
Entity type:Organization
Organization Name:ILLINOIS EXPRESS VIS CTR DNVLL INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:PARIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-446-5554
Mailing Address - Street 1:2807 N VERMILION ST
Mailing Address - Street 2:STE 4
Mailing Address - City:DANVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61832-1444
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2807 N VERMILION ST
Practice Address - Street 2:STE 4
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-1444
Practice Address - Country:US
Practice Address - Phone:217-446-5554
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2012-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-007720152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0884040001Medicare NSC