Healthcare Provider Details

I. General information

NPI: 1487802260
Provider Name (Legal Business Name): EYE BOUTIQUE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2008
Last Update Date: 08/22/2022
Certification Date: 08/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2509 COUNTY LINE RD
ALGONQUIN IL
60102-2566
US

IV. Provider business mailing address

16800 W CLEVELAND AVE
NEW BERLIN WI
53151-3533
US

V. Phone/Fax

Practice location:
  • Phone: 847-658-7661
  • Fax: 262-923-7675
Mailing address:
  • Phone: 262-432-2005
  • Fax: 262-432-2006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: MR. DARREN THOMAS HORNDASCH
Title or Position: PRESIDENT
Credential:
Phone: 262-432-2005