Healthcare Provider Details

I. General information

NPI: 1104021179
Provider Name (Legal Business Name): EAGLE OPTICAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2755 INDIANA AVE
LANSING IL
60438-2225
US

IV. Provider business mailing address

2755 INDIANA AVE
LANSING IL
60438-2225
US

V. Phone/Fax

Practice location:
  • Phone: 708-474-3500
  • Fax: 708-474-3556
Mailing address:
  • Phone: 708-474-3500
  • Fax: 708-474-3556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: MR. JAMES NOVAK
Title or Position: PRESIDENT
Credential:
Phone: 708-474-3500