Healthcare Provider Details

I. General information

NPI: 1326380510
Provider Name (Legal Business Name): DEKALB EYE CONSULTANTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2013
Last Update Date: 02/05/2020
Certification Date: 02/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1630 GATEWAY DR
SYCAMORE IL
60178-3155
US

IV. Provider business mailing address

PO BOX 1461
CHICAGO IL
60690-1461
US

V. Phone/Fax

Practice location:
  • Phone: 815-756-8571
  • Fax: 815-756-5603
Mailing address:
  • Phone: 815-756-8571
  • Fax: 815-756-1790

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: GEORGE L NEAL
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 469-214-0144