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General NPI Number Information
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NPI Number | 1477036671
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Entity Type | Organization
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Legal Business Name | CHICAGO LASIK CENTER, LLC
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Dates
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Enumeration Date | 09/13/2018
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Last Update Date | 06/13/2019
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Provider Practice Location Address
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Address Line | 405 N WABASH AVE STE P-2E
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City | CHICAGO
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State | IL
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Zip | 60611-3591
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Country | US
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Telephone | 708-536-8078
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Fax |
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Provider Business Mailing Address
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Address Line | 405 N WABASH AVE STE P2E
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City | CHICAGO
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State | IL
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Zip | 60611-3591
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Country | US
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Telephone | 312-955-0072
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Fax |
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Authorized Official
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Title or Position | MANAGING MEMBER/MEDICAL DIRECTOR
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Name | DR. JONATHAN STEPHAN MCGLOTHAN
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Credential | MD
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Telephone | 317-267-9014
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QS0132X
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Taxonomy Name | Ophthalmologic Surgery Clinic/Center
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License Number |
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License Number State |
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