Healthcare Provider Details

I. General information

NPI: 1508917618
Provider Name (Legal Business Name): LORI STAUCH O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1239 E OGDEN AVE SUITE 115
NAPERVILLE IL
60563-8545
US

IV. Provider business mailing address

1239 E OGDEN AVE SUITE 115
NAPERVILLE IL
60563-8545
US

V. Phone/Fax

Practice location:
  • Phone: 630-355-9797
  • Fax: 630-355-9796
Mailing address:
  • Phone: 630-355-9797
  • Fax: 630-355-9796

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: