Healthcare Provider Details

I. General information

NPI: 1972597342
Provider Name (Legal Business Name): GM REVELLE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 04/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2820 PLAINFIELD RD
JOLIET IL
60435-1167
US

IV. Provider business mailing address

2820 PLAINFIELD RD
JOLIET IL
60435-1167
US

V. Phone/Fax

Practice location:
  • Phone: 815-436-1144
  • Fax: 815-436-1260
Mailing address:
  • Phone: 815-436-1144
  • Fax: 815-436-1260

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: DR. DENNIS E DETTMANN
Title or Position: OWNER
Credential: O.D.
Phone: 815-436-1144