Healthcare Provider Details

I. General information

NPI: 1437486511
Provider Name (Legal Business Name): DIANE LIS O.D.S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2009
Last Update Date: 11/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 MEACHAM RD
ELK GROVE VLG IL
60007-3073
US

IV. Provider business mailing address

1904 MIDWEST CLUB PKWY
OAK BROOK IL
60523-2525
US

V. Phone/Fax

Practice location:
  • Phone: 847-584-7090
  • Fax: 847-548-7092
Mailing address:
  • Phone: 630-205-5222
  • Fax: 630-323-8171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046008227
License Number StateIL

VIII. Authorized Official

Name: DR. DIANE MARIE LIS
Title or Position: OPTOMETRIST
Credential: O.D.
Phone: 630-205-5222