Healthcare Provider Details

I. General information

NPI: 1104156009
Provider Name (Legal Business Name): WOW VISION PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2009
Last Update Date: 01/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7451 WOODWARD AVE SUITE 101
WOODRIDGE IL
60517-2665
US

IV. Provider business mailing address

7451 WOODWARD AVE SUITE 101
WOODRIDGE IL
60517-2665
US

V. Phone/Fax

Practice location:
  • Phone: 630-663-9112
  • Fax: 630-663-9228
Mailing address:
  • Phone: 630-663-9112
  • Fax: 630-663-9228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046009127
License Number StateIL

VIII. Authorized Official

Name: DR. MARK D WILMOTH
Title or Position: PRESIDENT AND CEO
Credential: OD
Phone: 630-663-9112