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General NPI Number Information
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NPI Number | 1265621361
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Entity Type | Organization
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Legal Business Name | HAROLD E DAVIS & TERRY ALAN TRUST ETAL
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Dates
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Enumeration Date | 10/15/2007
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Last Update Date | 07/01/2025
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Provider Practice Location Address
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Address Line | 4663 W 95TH ST
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City | OAK LAWN
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State | IL
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Zip | 60453-2540
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Country | US
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Telephone | 708-636-0600
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Fax | 708-636-0606
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Provider Business Mailing Address
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Address Line | 4663 W 95TH ST
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City | OAK LAWN
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State | IL
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Zip | 60453-2540
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Country | US
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Telephone | 708-636-0600
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Fax | 708-636-0606
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Authorized Official
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Title or Position | ADMINISTRATIVE ASST.
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Name | MS. JASON DAVIS
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Credential |
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Telephone | 708-636-0600
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 305R00000X
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Taxonomy Name | Preferred Provider Organization
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License Number | 046004083
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 305R00000X
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Taxonomy Name | Preferred Provider Organization
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License Number | 046007173
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License Number State | IL
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Taxonomy #3
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Taxonomy Code | 305R00000X
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Taxonomy Name | Preferred Provider Organization
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License Number | 046009277
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License Number State | IL
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Taxonomy #4
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number |
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License Number State |
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