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General NPI Number Information
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NPI Number | 1538466560
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Entity Type | Organization
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Legal Business Name | DIABETIC EYE CENTERS OF AMERICA, INCORPORATED
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Dates
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Enumeration Date | 02/28/2011
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Last Update Date | 09/25/2013
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Provider Practice Location Address
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Address Line | 22 W HARRIS AVE
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City | LA GRANGE
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State | IL
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Zip | 60525-2332
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Country | US
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Telephone | 708-639-4270
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Fax | 708-639-4271
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Provider Business Mailing Address
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Address Line | 22 W HARRIS AVE
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City | LA GRANGE
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State | IL
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Zip | 60525-2332
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Country | US
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Telephone | 708-639-4270
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Fax | 708-639-4271
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Authorized Official
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Title or Position | STAFF
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Name | MISS NICOLE P. LAFINE
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Credential |
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Telephone | 708-499-0123
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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 | 046010097
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License Number State | IL
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