Healthcare Provider Details

I. General information

NPI: 1972027472
Provider Name (Legal Business Name): ILLINOIS EYE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2017
Last Update Date: 07/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1630 GATEWAY DR
SYCAMORE IL
60178-3182
US

IV. Provider business mailing address

2727 N HARWOOD ST STE 250
DALLAS TX
75201-2410
US

V. Phone/Fax

Practice location:
  • Phone: 815-756-8571
  • Fax: 815-756-5603
Mailing address:
  • Phone: 844-377-6468
  • Fax: 469-677-6260

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. MICHAEL T. FRICKE
Title or Position: SECRETARY
Credential:
Phone: 844-377-6468