Healthcare Provider Details

I. General information

NPI: 1235288564
Provider Name (Legal Business Name): CLC VISION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7317 W 25TH STREET
NORTH RIVERSIDE IL
60546
US

IV. Provider business mailing address

7317 W 25TH STREET
NORTH RIVERSIDE IL
60546
US

V. Phone/Fax

Practice location:
  • Phone: 708-442-8899
  • Fax: 708-442-9466
Mailing address:
  • Phone: 708-442-8899
  • Fax: 708-442-9466

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number
License Number StateIL

VIII. Authorized Official

Name: DR. COLBY LEE CARTER
Title or Position: OWNER
Credential: O.D.
Phone: 708-442-8899