Healthcare Provider Details

I. General information

NPI: 1992710578
Provider Name (Legal Business Name): ERWIN CABELA O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4113 SAINT CHARLES RD
BELLWOOD IL
60104-1145
US

IV. Provider business mailing address

801 12TH AVE
LA GRANGE IL
60525-3118
US

V. Phone/Fax

Practice location:
  • Phone: 708-493-9306
  • Fax: 708-493-0144
Mailing address:
  • Phone: 708-369-7346
  • Fax: 708-493-0144

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046009094
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: