Healthcare Provider Details

I. General information

NPI: 1417364167
Provider Name (Legal Business Name): TIFFANY LUE O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2014
Last Update Date: 02/09/2022
Certification Date: 02/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3224 RIDGE RD STE 102
LANSING IL
60438-3191
US

IV. Provider business mailing address

1950 OLD GALLOWS RD STE 520
VIENNA VA
22182-3970
US

V. Phone/Fax

Practice location:
  • Phone: 703-895-4422
  • Fax: 708-895-4482
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046.010833
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: