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General NPI Number Information
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NPI Number | 1376845800
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Entity Type | Organization
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Legal Business Name | MICHAEL MENCONI, OD. PC.
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Dates
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Enumeration Date | 12/05/2010
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Last Update Date | 06/09/2011
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Provider Practice Location Address
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Address Line | 1112 E RAILROAD ST STE 1
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City | SANDWICH
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State | IL
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Zip | 60548-1894
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Country | US
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Telephone | 630-786-2020
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Fax | 630-786-6306
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Provider Business Mailing Address
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Address Line | 1112 E RAILROAD ST STE 1
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City | SANDWICH
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State | IL
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Zip | 60548-1894
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Country | US
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Telephone | 630-786-2020
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Fax | 630-786-6306
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MICHAEL WILLIAM MENCONI
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Credential | O.D.
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Telephone | 630-608-8287
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 046010227
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License Number State | IL
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