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NPI Code Detail

MEDICARE: NORTH SHORE OPTICAL INC.

MEDICARE: NORTH SHORE OPTICAL 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
1152W00000XOptometrist046007174IL

General Provider Information

NPI Number : 1952612111
Entity Type Code : Organization
Provider Name (Legal Business Name) : NORTH SHORE OPTICAL INC.
Provider Business Mailing Address
First Line : 5257 N BROADWAY ST
Second Line :
City : CHICAGO
State : IL
Zip : 60640-2303
Country : US
Telephone Number : 773-878-5197
Fax Number : 773-878-5398
Provider Business Practice Location Address
First Line : 5257 N BROADWAY ST
Second Line :
City : CHICAGO
State : IL
Zip : 60640-2303
Country : US
Telephone Number : 773-878-5197
Fax Number : 773-878-5398
Authorized Official
Title or Position : OWNER
Name : DR. DAVID D DEWAARD
Credential : O. D.
Telephone Number : 773-878-5197
Provider Enumeration Date : 06/23/2010
Last Update Date : 06/23/2010

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Directions to “NORTH SHORE OPTICAL INC. ” Practice Location

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