Healthcare Provider Details

I. General information

NPI: 1750407326
Provider Name (Legal Business Name): CARILLON VISION CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 03/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 WAUKEGAN RD
GLENVIEW IL
60025-1714
US

IV. Provider business mailing address

1900 WAUKEGAN ROAD
GLENVIEW IL
60025-1714
US

V. Phone/Fax

Practice location:
  • Phone: 847-657-8787
  • Fax: 847-657-8730
Mailing address:
  • Phone: 847-657-8787
  • Fax: 847-657-8730

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number0718540001
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number464927
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number467979
License Number StateIL

VIII. Authorized Official

Name: DR. JEROME AGREST
Title or Position: PARTNER OWNER
Credential: OD
Phone: 847-657-8787