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General NPI Number Information
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NPI Number | 1588727663
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Entity Type | Organization
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Legal Business Name | GLEN ELLYN VISION CENTER PC
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Dates
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Enumeration Date | 12/19/2006
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Last Update Date | 05/18/2010
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Provider Practice Location Address
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Address Line | 440 N MAIN ST
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City | GLEN ELLYN
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State | IL
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Zip | 60137-5124
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Country | US
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Telephone | 630-469-4141
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Fax | 630-469-2015
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Provider Business Mailing Address
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Address Line | 440 N MAIN ST
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City | GLEN ELLYN
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State | IL
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Zip | 60137-5124
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Country | US
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Telephone | 630-469-4141
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Fax | 630-469-2015
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MARTIN J SIKORSKI
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Credential | OD
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Telephone | 630-469-4141
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152WC0802X
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Taxonomy Name | Corneal and Contact Management Optometrist
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License Number | 046.006197
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 152WP0200X
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Taxonomy Name | Pediatric Optometrist
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License Number | 046.006197
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License Number State | IL
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Taxonomy #3
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Taxonomy Code | 152WV0400X
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Taxonomy Name | Vision Therapy Optometrist
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License Number | 046.006197
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License Number State | IL
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Taxonomy #4
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 046.006197
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License Number State | IL
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