Healthcare Provider Details

I. General information

NPI: 1891041364
Provider Name (Legal Business Name): NIKOGOSIAN VISION CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2012
Last Update Date: 08/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

558 W GALETON DR
ROUND LAKE IL
60073-5605
US

IV. Provider business mailing address

558 W GALETON DR
ROUND LAKE IL
60073-5605
US

V. Phone/Fax

Practice location:
  • Phone: 847-293-6906
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046010459
License Number StateIL

VIII. Authorized Official

Name: DR. KARINA NIKOGOSIAN
Title or Position: PRESIDENT/OPTOMETRIST
Credential: O.D.
Phone: 847-293-6906