Healthcare Provider Details

I. General information

NPI: 1417050311
Provider Name (Legal Business Name): FREDERICK JOHN KAHLE O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10260 S. HARLEM AVE WAL-MART VISION CENTER
BRIDGEVIEW IL
60455
US

IV. Provider business mailing address

522 REGAN DR
EAST DUNDEE IL
60118-3027
US

V. Phone/Fax

Practice location:
  • Phone: 708-499-2988
  • Fax: 708-499-3057
Mailing address:
  • Phone: 847-844-6973
  • 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: