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General NPI Number Information
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NPI Number | 1245781269
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Entity Type | Organization
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Legal Business Name | MILT88 INC
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Dates
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Enumeration Date | 10/14/2016
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Last Update Date | 10/14/2016
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Provider Practice Location Address
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Address Line | 6501 95TH ST SEARS OPTICAL
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City | CHICAGO RIDGE
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State | IL
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Zip | 60415-2632
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Country | US
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Telephone | 708-499-4676
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Fax |
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Provider Business Mailing Address
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Address Line | 3946 JOHNSON AVE
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City | WESTERN SPRINGS
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State | IL
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Zip | 60558-1139
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MICHAEL TABERNACKI
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Credential | O.D.
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Telephone | 708-601-2688
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 046-008140
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License Number State | IL
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