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General NPI Number Information
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NPI Number | 1508986175
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Entity Type | Organization
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Legal Business Name | SHORELAND OPTICAL CO #27 INC.
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Dates
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Enumeration Date | 03/29/2007
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Last Update Date | 12/17/2014
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Provider Practice Location Address
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Address Line | 3136 N LINCOLN AVE
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City | CHICAGO
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State | IL
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Zip | 60657-3117
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Country | US
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Telephone | 773-871-8210
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Fax |
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Provider Business Mailing Address
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Address Line | 3136 N LINCOLN AVE
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City | CHICAGO
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State | IL
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Zip | 60657-3117
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Country | US
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Telephone | 773-871-8210
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. RALPH GEIDERMAN
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Credential | O.D.
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Telephone | 773-871-8210
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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 | IL046007178
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License Number State | IL
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