Healthcare Provider Details

I. General information

NPI: 1578655593
Provider Name (Legal Business Name): INDUSTRIAL OPTICAL SERVICE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 11/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4418 W DIVERSEY AVE
CHICAGO IL
60639-1924
US

IV. Provider business mailing address

4418 W DIVERSEY AVE
CHICAGO IL
60639-1924
US

V. Phone/Fax

Practice location:
  • Phone: 773-736-6800
  • Fax:
Mailing address:
  • Phone: 773-736-6800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: CARRIE ROITSTEIN
Title or Position: OPTOMETRIST
Credential: O.D.
Phone: 312-673-7192