Healthcare Provider Details

I. General information

NPI: 1972615391
Provider Name (Legal Business Name): SKK OPTOMETRISTS LIMITED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 06/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

534 N RAND RD C/O LAKE ZURICH EYECARE
LAKE ZURICH IL
60047-3103
US

IV. Provider business mailing address

534 N RAND RD C/O LAKE ZURICH EYECARE
LAKE ZURICH IL
60047-3103
US

V. Phone/Fax

Practice location:
  • Phone: 847-997-1477
  • Fax:
Mailing address:
  • Phone: 847-997-1477
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number46009065
License Number StateIL

VIII. Authorized Official

Name: DR. SCOTT D POUYAT
Title or Position: PRESIDENT
Credential: O.D
Phone: 847-997-1477