=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063987345
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHATAAM OPTICAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/12/2018
-----------------------------------------------------
Last Update Date | 10/12/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8741 S GREENWOOD AVE STE 108
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60619-7058
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-933-0276
-----------------------------------------------------
Fax | 773-933-0278
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8741 S GREENWOOD AVE STE 108
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60619-7058
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-933-0276
-----------------------------------------------------
Fax | 773-933-0278
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. ONTAVIUS PERKINS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 773-793-9723
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------