Healthcare Provider Details

I. General information

NPI: 1720182165
Provider Name (Legal Business Name): THERESE MARIE PORRETTA O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1410 S RANDALL RD
ALGONQUIN IL
60102-5919
US

IV. Provider business mailing address

620 ECHO TRL
MARENGO IL
60152-8058
US

V. Phone/Fax

Practice location:
  • Phone: 847-458-5796
  • Fax:
Mailing address:
  • Phone: 708-261-4902
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: