Healthcare Provider Details

I. General information

NPI: 1104040328
Provider Name (Legal Business Name): JACK SHAW SUPERIOR EYE CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 08/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2906 N BROADWAY ST
CHICAGO IL
60657-7163
US

IV. Provider business mailing address

2906 N BROADWAY ST
CHICAGO IL
60657-7163
US

V. Phone/Fax

Practice location:
  • Phone: 773-525-1601
  • Fax: 773-435-4210
Mailing address:
  • Phone: 773-525-1601
  • Fax: 773-435-4210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State

VIII. Authorized Official

Name: MR. JACK SHAW
Title or Position: OWNER
Credential: OPTICIAN
Phone: 773-525-1601