MEDICARE: GUSTAFSON EYECARE INC

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	:	1013188374
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GUSTAFSON EYECARE INC

Provider Business Mailing Address
First Line	:	1140 DOUGLAS RD
Second Line	:
City	:	OSWEGO
State	:	IL
Zip	:	60543-9040
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1140 DOUGLAS RD
Second Line	:
City	:	OSWEGO
State	:	IL
Zip	:	60543-9040
Country	:	US
Telephone Number	:	630-554-5188
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	STEVE GUSTAFSON
Credential	:
Telephone Number	:	630-554-5188

Provider Enumeration Date	:	03/14/2008
Last Update Date	:	03/14/2008

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