Healthcare Provider Details

I. General information

NPI: 1639252273
Provider Name (Legal Business Name): NORTHERN ILLINOIS OPTICAL CO., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 11/07/2024
Certification Date: 11/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 N MADISON ST
ROCKFORD IL
61107-3949
US

IV. Provider business mailing address

121 N MADISON ST
ROCKFORD IL
61107-3949
US

V. Phone/Fax

Practice location:
  • Phone: 815-963-3454
  • Fax: 815-963-4384
Mailing address:
  • Phone: 815-963-3454
  • Fax: 815-963-4384

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State

VIII. Authorized Official

Name: SHERI M DE ROSSO
Title or Position: OWNER
Credential:
Phone: 815-963-3454