MEDICARE: ELITE EYE CARE, LLC

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

General Provider Information

NPI Number	:	1306314794
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELITE EYE CARE, LLC

Provider Business Mailing Address
First Line	:	5438 S 74TH AVE
Second Line	:
City	:	SUMMIT
State	:	IL
Zip	:	60501-1013
Country	:	US
Telephone Number	:	312-614-2020
Fax Number	:

Provider Business Practice Location Address
First Line	:	555 S DEARBORN ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60605-1586
Country	:	US
Telephone Number	:	312-614-2020
Fax Number	:	312-626-5139

Authorized Official
Title or Position	:	SOLE OWNER
Name	:	DR. MATTHEW DANIEL PIETRUSZKA
Credential	:	OD
Telephone Number	:	708-256-5135

Provider Enumeration Date	:	11/05/2018
Last Update Date	:	12/03/2018

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