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General NPI Number Information
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NPI Number | 1346716768
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Entity Type | Organization
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Legal Business Name | LINCOLN SQUARE OPTICAL
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Dates
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Enumeration Date | 10/23/2018
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Last Update Date | 10/23/2018
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Provider Practice Location Address
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Address Line | 2501 W LAWRENCE AVE
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City | CHICAGO
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State | IL
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Zip | 60625-2958
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Country | US
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Telephone | 773-931-3839
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Fax |
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Provider Business Mailing Address
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Address Line | 5232 WRIGHT TER
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City | SKOKIE
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State | IL
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Zip | 60077-2161
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Country | US
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Telephone | 773-931-3839
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Fax |
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Authorized Official
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Title or Position | OPTOMETRIST
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Name | MARIAM ETHEZAZ
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Credential | OD
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Telephone | 773-931-3839
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152WC0802X
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Taxonomy Name | Corneal and Contact Management Optometrist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 152WL0500X
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Taxonomy Name | Low Vision Rehabilitation Optometrist
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 152WP0200X
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Taxonomy Name | Pediatric Optometrist
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 152WV0400X
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Taxonomy Name | Vision Therapy Optometrist
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License Number |
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License Number State |
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Taxonomy #5
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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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