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General NPI Number Information
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NPI Number | 1528873684
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Entity Type | Organization
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Legal Business Name | FOF OPTICAL PLLC
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Dates
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Enumeration Date | 02/07/2025
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Last Update Date | 02/27/2025
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Provider Practice Location Address
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Address Line | 372 LARRY POWER RD
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City | BOURBONNAIS
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State | IL
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Zip | 60914-5190
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Country | US
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Telephone | 708-805-7618
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Fax |
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Provider Business Mailing Address
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Address Line | 1158 LAFITE
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City | BOURBONNAIS
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State | IL
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Zip | 60914-4538
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Country | US
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Telephone | 708-805-7618
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Fax |
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Authorized Official
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Title or Position | OPTOMETRIST
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Name | DR. LISA MARIE JEZIORNY KEROUAC
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Credential | OD
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Telephone | 708-805-7618
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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 |
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License Number State |
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