Healthcare Provider Details

I. General information

NPI: 1285612390
Provider Name (Legal Business Name): ILLINOIS COLLEGE OF OPTOMETRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2006
Last Update Date: 01/08/2021
Certification Date: 01/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3241 S MICHIGAN AVENUE
CHICAGO IL
60616-3878
US

IV. Provider business mailing address

3241 S MICHIGAN AVENUE
CHICAGO IL
60616-3878
US

V. Phone/Fax

Practice location:
  • Phone: 312-225-6200
  • Fax: 312-949-7660
Mailing address:
  • Phone: 312-225-6200
  • Fax: 312-949-7660

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number8720518
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: MARK COLIP
Title or Position: PRESIDENT
Credential: OD
Phone: 312-949-7701