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General NPI Number Information
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NPI Number | 1174072276
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Entity Type | Organization
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Legal Business Name | EYEPOTHECARY
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Dates
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Enumeration Date | 09/30/2016
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Last Update Date | 09/30/2016
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Provider Practice Location Address
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Address Line | 1726 W CHICAGO AVE
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City | CHICAGO
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State | IL
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Zip | 60622-5000
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Country | US
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Telephone | 773-782-1744
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Fax | 312-733-1744
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Provider Business Mailing Address
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Address Line | 1726 W CHICAGO AVE
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City | CHICAGO
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State | IL
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Zip | 60622-5000
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Country | US
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Telephone | 773-782-1744
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Fax | 312-733-1744
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Authorized Official
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Title or Position | PRESIDENT
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Name | MS. ANNETTE ELAINE SOLLARS III
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Credential | OPTICIAN
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Telephone | 773-782-1744
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 335E00000X
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Taxonomy Name | Prosthetic/Orthotic Supplier
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License Number | 04739116
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License Number State | IL
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