Healthcare Provider Details

I. General information

NPI: 1477804912
Provider Name (Legal Business Name): MARENGO VISION CENTER, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2012
Last Update Date: 09/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3920 N JOHNSBURG RD
JOHNSBURG IL
60051-6320
US

IV. Provider business mailing address

3920 N JOHNSBURG RD
JOHNSBURG IL
60051-6320
US

V. Phone/Fax

Practice location:
  • Phone: 815-385-0002
  • Fax:
Mailing address:
  • Phone: 815-385-0002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046009334
License Number StateIL

VIII. Authorized Official

Name: MICHAEL THOMAS
Title or Position: PRESIDENT
Credential: O.D.
Phone: 815-568-6508