MEDICARE: LA VALLEE OPTOMETRIC 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	046009075	IL

General Provider Information

NPI Number	:	1851459481
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LA VALLEE OPTOMETRIC LTD.

Provider Business Mailing Address
First Line	:	2111 W SUPERIOR ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60612-1315
Country	:	US
Telephone Number	:	773-895-3411
Fax Number	:	312-226-0802

Provider Business Practice Location Address
First Line	:	2111 W SUPERIOR ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60612-1315
Country	:	US
Telephone Number	:	773-895-3411
Fax Number	:	312-226-0802

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. KEITH LA VALLEE
Credential	:	O.D.
Telephone Number	:	773-895-3411

Provider Enumeration Date	:	12/05/2006
Last Update Date	:	09/29/2008

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