Healthcare Provider Details

I. General information

NPI: 1215138771
Provider Name (Legal Business Name): GUSTAFSON EYE CARE CLINICS, LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 03/13/2020
Certification Date: 03/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

96 W NORTHWEST HWY
PALATINE IL
60067-3571
US

IV. Provider business mailing address

96 W NORTHWEST HWY
PALATINE IL
60067-3571
US

V. Phone/Fax

Practice location:
  • Phone: 847-358-7722
  • Fax: 847-520-3280
Mailing address:
  • Phone: 847-358-7722
  • Fax: 847-520-3280

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046008241
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: DR. THOMAS EARL GUSTAFSON
Title or Position: PRESIDENT
Credential: O.D.
Phone: 847-638-7308