MEDICARE: SCOTT EYE CARE LTD.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist		IL

General Provider Information

NPI Number	:	1013121433
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SCOTT EYE CARE LTD.

Provider Business Mailing Address
First Line	:	1335 DOUGLAS RD
Second Line	:	SUITE E
City	:	MONTGOMERY
State	:	IL
Zip	:	60538-1634
Country	:	US
Telephone Number	:	630-844-0908
Fax Number	:	630-844-0677

Provider Business Practice Location Address
First Line	:	1335 DOUGLAS RD
Second Line	:	SUITE E
City	:	MONTGOMERY
State	:	IL
Zip	:	60538-1634
Country	:	US
Telephone Number	:	630-844-0908
Fax Number	:	630-844-0677

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. CHULA LERDVORATAVEE
Credential	:	O.D.
Telephone Number	:	630-844-0908

Provider Enumeration Date	:	05/09/2007
Last Update Date	:	08/22/2020

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