=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538489737
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTH SHORE OPTICAL INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/10/2010
-----------------------------------------------------
Last Update Date | 06/10/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7559 N PAULINA ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60626-1692
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-764-3873
-----------------------------------------------------
Fax | 773-465-4893
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7559 N PAULINA ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60626-1692
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-764-3873
-----------------------------------------------------
Fax | 773-465-4893
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. DAVID D DEWAARD
-----------------------------------------------------
Credential | O. D.
-----------------------------------------------------
Telephone | 773-764-3873
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 046007174
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------