Healthcare Provider Details

I. General information

NPI: 1265621361
Provider Name (Legal Business Name): HAROLD E DAVIS & TERRY ALAN TRUST ETAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2007
Last Update Date: 07/01/2025
Certification Date: 07/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4663 W 95TH ST
OAK LAWN IL
60453-2540
US

IV. Provider business mailing address

4663 W 95TH ST
OAK LAWN IL
60453-2540
US

V. Phone/Fax

Practice location:
  • Phone: 708-636-0600
  • Fax: 708-636-0606
Mailing address:
  • Phone: 708-636-0600
  • Fax: 708-636-0606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number046004083
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number046007173
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number046009277
License Number StateIL

VIII. Authorized Official

Name: MS. JASON DAVIS
Title or Position: ADMINISTRATIVE ASST.
Credential:
Phone: 708-636-0600