Healthcare Provider Details

I. General information

NPI: 1871794362
Provider Name (Legal Business Name): LAKESIDE EYE CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 S MICHIGAN AVE 410
CHICAGO IL
60603-5902
US

IV. Provider business mailing address

104 S MICHIGAN AVE 410
CHICAGO IL
60603-5902
US

V. Phone/Fax

Practice location:
  • Phone: 312-553-1818
  • Fax: 312-641-5503
Mailing address:
  • Phone: 312-553-1818
  • Fax: 312-641-5503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number
License Number StateIL

VIII. Authorized Official

Name: MR. ERNESTO CARRASCO
Title or Position: PRESIDENT
Credential:
Phone: 312-553-1818