Healthcare Provider Details

I. General information

NPI: 1356559595
Provider Name (Legal Business Name): CONCEPT EYE CARE, LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2007
Last Update Date: 07/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1605 E 55TH ST 1ST FLR
CHICAGO IL
60615-5803
US

IV. Provider business mailing address

1605 E 55TH ST 1ST FLR
CHICAGO IL
60615-5803
US

V. Phone/Fax

Practice location:
  • Phone: 773-363-0202
  • Fax: 773-363-0201
Mailing address:
  • Phone: 773-363-0202
  • Fax: 773-363-0201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number0046008464
License Number StateIL

VIII. Authorized Official

Name: DR. CYNTHIA LORRAIN REYNOLDS-TEMPLE
Title or Position: PRESIDENT
Credential: O.D.
Phone: 773-363-0202