MEDICARE: ELLEN KOZOB, 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	046010698	IL

General Provider Information

NPI Number	:	1184009730
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELLEN KOZOB, INC

Provider Business Mailing Address
First Line	:	2131 N LARRABEE ST
Second Line	:	UNIT 6107
City	:	CHICAGO
State	:	IL
Zip	:	60614-4444
Country	:	US
Telephone Number	:	224-622-0907
Fax Number	:

Provider Business Practice Location Address
First Line	:	2131 N LARRABEE ST
Second Line	:	UNIT 6107
City	:	CHICAGO
State	:	IL
Zip	:	60614-4444
Country	:	US
Telephone Number	:	224-622-0907
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. ELLEN R KOZOB
Credential	:	O.D.
Telephone Number	:	224-622-0907

Provider Enumeration Date	:	07/24/2015
Last Update Date	:	07/24/2015

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