Healthcare Provider Details

I. General information

NPI: 1588727663
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: 05/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 N MAIN ST
GLEN ELLYN IL
60137-5124
US

IV. Provider business mailing address

440 N MAIN ST
GLEN ELLYN IL
60137-5124
US

V. Phone/Fax

Practice location:
  • Phone: 630-469-4141
  • Fax: 630-469-2015
Mailing address:
  • Phone: 630-469-4141
  • Fax: 630-469-2015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number046.006197
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number046.006197
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number046.006197
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046.006197
License Number StateIL

VIII. Authorized Official

Name: DR. MARTIN J SIKORSKI
Title or Position: PRESIDENT
Credential: OD
Phone: 630-469-4141