Healthcare Provider Details

I. General information

NPI: 1578719308
Provider Name (Legal Business Name): ASSOCIATED OPTICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2008
Last Update Date: 08/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4050 HEALTHWAY DR SUITE 100
AURORA IL
60504-8183
US

IV. Provider business mailing address

4050 HEALTHWAY DR SUITE 100
AURORA IL
60504-8183
US

V. Phone/Fax

Practice location:
  • Phone: 630-820-1303
  • Fax:
Mailing address:
  • Phone: 630-820-1303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046009482
License Number StateIL

VIII. Authorized Official

Name: DR. CARRIE SPENCER SYPHERD
Title or Position: DOCTOR
Credential: O.D.
Phone: 630-820-1303