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General NPI Number Information
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NPI Number | 1639367980
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Entity Type | Organization
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Legal Business Name | KENNETH PORTNOY
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Dates
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Enumeration Date | 10/11/2007
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Last Update Date | 03/24/2021
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Provider Practice Location Address
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Address Line | 727 W DUNDEE RD
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City | WHEELING
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State | IL
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Zip | 60090-2605
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Country | US
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Telephone | 847-459-4477
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Fax | 847-459-4535
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Provider Business Mailing Address
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Address Line | 727 W DUNDEE RD
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City | WHEELING
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State | IL
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Zip | 60090-2605
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Country | US
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Telephone | 847-459-4477
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Fax | 847-459-4535
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Authorized Official
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Title or Position | OWNER
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Name | DR. KENNETH PORTNOY
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Credential | OD
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Telephone | 847-459-4477
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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 | 1622-6070
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License Number State | IL
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