Healthcare Provider Details

I. General information

NPI: 1225351471
Provider Name (Legal Business Name): GEL M GOWIN,INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2010
Last Update Date: 03/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3541 W 95TH ST
EVERGREEN PARK IL
60805-2135
US

IV. Provider business mailing address

3541 W 95TH ST
EVERGREEN PARK IL
60805-2135
US

V. Phone/Fax

Practice location:
  • Phone: 708-425-4162
  • Fax: 708-425-8708
Mailing address:
  • Phone: 708-425-4162
  • Fax: 708-425-8708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number37582585
License Number StateIL

VIII. Authorized Official

Name: ANGELITA M GOWIN
Title or Position: OWNER
Credential:
Phone: 708-425-4162