Healthcare Provider Details

I. General information

NPI: 1689780645
Provider Name (Legal Business Name): EYES ON THE LAKE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 GREEN BAY RD
KENILWORTH IL
60043-1075
US

IV. Provider business mailing address

420 GREEN BAY RD.
KENILWORTH IL
60043-1075
US

V. Phone/Fax

Practice location:
  • Phone: 847-853-1111
  • Fax:
Mailing address:
  • Phone: 847-853-1111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046-09022
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046-08599
License Number StateIL

VIII. Authorized Official

Name: DR. WILLIAM R NAJEM
Title or Position: VICE PRESIDENT
Credential: O.D.
Phone: 847-853-1111