Healthcare Provider Details

I. General information

NPI: 1356404354
Provider Name (Legal Business Name): GLEN ELLYN VISION CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 07/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1245 LARKIN AVE
ELGIN IL
60123-6033
US

IV. Provider business mailing address

1245 LARKIN AVE
ELGIN IL
60123-6033
US

V. Phone/Fax

Practice location:
  • Phone: 847-695-2020
  • Fax: 847-695-2242
Mailing address:
  • Phone: 847-695-2020
  • Fax: 847-695-2242

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046.008870
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number046.008870
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number046.008870
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number046.008870
License Number StateIL

VIII. Authorized Official

Name: DR. MARTIN J SIKORSKI
Title or Position: PRESIDENT
Credential: OD
Phone: 847-695-2020