| NPI | 1669444063 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | MARIE ANNETTE MANGRUM Board Secretary/Treas. 618-466-8787 |
| Organization Subpart ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: IL 22652655) |
| Enumeration Date | 2006-02-02 |
| Last Update Date | 2011-08-29 |