=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669596896
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DRS LUCKHARDT AND MAZE LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/16/2007
-----------------------------------------------------
Last Update Date | 04/09/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 136 N. CASS AVE
-----------------------------------------------------
City | WESTMONT
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60559
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-969-2807
-----------------------------------------------------
Fax | 630-969-2894
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 136 N. CASS AVE
-----------------------------------------------------
City | WESTMONT
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60559
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-969-2807
-----------------------------------------------------
Fax | 630-969-2894
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. DAVID A. MAZE
-----------------------------------------------------
Credential | O.D..
-----------------------------------------------------
Telephone | 630-969-2807
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 060008794
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------