Healthcare Provider Details

I. General information

NPI: 1508680257
Provider Name (Legal Business Name): MYEYEDR OPTOMETRY OF ILLINOIS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/11/2024
Last Update Date: 11/14/2024
Certification Date: 11/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24510 W LOCKPORT ST STE 100
PLAINFIELD IL
60544-2312
US

IV. Provider business mailing address

8614 WESTWOOD CENTER DR FL 9
VIENNA VA
22182-2442
US

V. Phone/Fax

Practice location:
  • Phone: 815-254-2546
  • Fax: 815-254-2566
Mailing address:
  • Phone: 703-847-8899
  • Fax: 571-223-6780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: SUE DOWNES
Title or Position: SECRETARY
Credential:
Phone: 703-847-8899