=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275802605
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCED FAMILY EYECARE CENTER OF BOLINGBROOK,INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2011
-----------------------------------------------------
Last Update Date | 08/30/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 480 W BOUGHTON RD
-----------------------------------------------------
City | BOLINGBROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60440-1890
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-759-6506
-----------------------------------------------------
Fax | 630-759-6651
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13165 RAPHAEL ST
-----------------------------------------------------
City | LEMONT
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60439-9164
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-759-6506
-----------------------------------------------------
Fax | 630-759-6651
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JOSEPH WILLIAM SUBAK JR.
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 630-759-6506
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 046-007833
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------