Healthcare Provider Details

I. General information

NPI: 1669636270
Provider Name (Legal Business Name): MIDWEST EYE CLINIC, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2008
Last Update Date: 07/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6254 S PULASKI RD
CHICAGO IL
60629-4610
US

IV. Provider business mailing address

6254 S PULASKI RD
CHICAGO IL
60629-4610
US

V. Phone/Fax

Practice location:
  • Phone: 773-581-1515
  • Fax: 773-581-9663
Mailing address:
  • Phone: 773-581-1515
  • Fax: 773-581-9663

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number346002682
License Number StateIL

VIII. Authorized Official

Name: MR. ERNESTO CARRASCO
Title or Position: PRESIDENT
Credential:
Phone: 773-581-1515