=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184140014
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EFP OPTICIANS ON DEARBORN, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/22/2017
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1205 N DEARBORN ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60610-2213
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-943-2020
-----------------------------------------------------
Fax | 312-275-7189
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1205 N DEARBORN ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60610-2213
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-943-2020
-----------------------------------------------------
Fax | 312-275-7189
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | GENERAL MANAGER
-----------------------------------------------------
Name | MR. BOYCE MOFFITT
-----------------------------------------------------
Credential | OPTICIAN, ABOC
-----------------------------------------------------
Telephone | 312-943-2020
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 156FX1800X
-----------------------------------------------------
Taxonomy Name | Optician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------