Healthcare Provider Details

I. General information

NPI: 1003896671
Provider Name (Legal Business Name): LAURA CRETORS O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

884 HILLSIDE AVE
ANTIOCH IL
60002-1226
US

IV. Provider business mailing address

120 KNOBB HILL LN
GURNEE IL
60031-2597
US

V. Phone/Fax

Practice location:
  • Phone: 847-395-4090
  • Fax: 847-395-7378
Mailing address:
  • Phone: 847-855-1743
  • 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: