=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285332676
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STACI W DUCKER OD LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/16/2023
-----------------------------------------------------
Last Update Date | 02/16/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2746 N CLYBOURN AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60614-1006
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-540-2558
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 88 GREENBRIAR EAST DR
-----------------------------------------------------
City | DEERFIELD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60015-5065
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-540-2558
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OD
-----------------------------------------------------
Name | STACI DUCKER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 954-540-2558
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------