Healthcare Provider Details

I. General information

NPI: 1699802421
Provider Name (Legal Business Name): THE EYE SPECIALISTS CENTER, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 04/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10436 SOUTHWEST HWY
CHICAGO RIDGE IL
60415-2282
US

IV. Provider business mailing address

DEPARTMENT 4684
CAROL STREAM IL
60122-4684
US

V. Phone/Fax

Practice location:
  • Phone: 708-423-4070
  • Fax: 708-423-4216
Mailing address:
  • Phone: 708-952-0109
  • Fax: 708-952-0329

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code156FX1202X
TaxonomyOptometric Technician
License Number
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. BENJAMIN HENDRICK TICHO
Title or Position: OWNER/PARTNER/PHYSICIAN
Credential: M.D.
Phone: 708-423-4070