Healthcare Provider Details

I. General information

NPI: 1548409501
Provider Name (Legal Business Name): COMPASS EYE CARE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2009
Last Update Date: 12/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

603 MADISON ST
OAK PARK IL
60302-4437
US

IV. Provider business mailing address

603 MADISON ST
OAK PARK IL
60302-4437
US

V. Phone/Fax

Practice location:
  • Phone: 708-383-2150
  • Fax: 708-383-2553
Mailing address:
  • Phone: 708-383-2150
  • Fax: 708-383-2553

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046.009863
License Number StateIL

VIII. Authorized Official

Name: DR. ALBERT SIMON LICUP
Title or Position: PRESIDENT
Credential: O.D.
Phone: 708-383-2150