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General NPI Number Information
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NPI Number | 1447595780
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Entity Type | Organization
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Legal Business Name | MALIK EYE INSTITUTE LLC
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Dates
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Enumeration Date | 11/27/2012
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Last Update Date | 09/06/2013
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Provider Practice Location Address
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Address Line | 4857 MANHATTAN DR
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City | ROCKFORD
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State | IL
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Zip | 61108-2265
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Country | US
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Telephone | 815-399-0599
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Fax | 815-399-5543
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Provider Business Mailing Address
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Address Line | 4857 MANHATTAN DR
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City | ROCKFORD
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State | IL
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Zip | 61108-2265
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Country | US
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Telephone | 815-399-0599
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Fax | 815-399-2499
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Authorized Official
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Title or Position | MANAGER
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Name | MRS. RANAE D BERGMAN
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Credential |
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Telephone | 815-399-2190
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number | 036-110588
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License Number State | IL
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