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General NPI Number Information
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NPI Number | 1679823132
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Entity Type | Organization
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Legal Business Name | EYEDOCTORS PC
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Dates
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Enumeration Date | 09/12/2012
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Last Update Date | 09/18/2012
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Provider Practice Location Address
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Address Line | 9621 N MILWAUKEE AVE
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City | NILES
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State | IL
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Zip | 60714-1116
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Country | US
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Telephone | 847-965-3791
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Fax | 847-965-3947
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Provider Business Mailing Address
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Address Line | 9621 N MILWAUKEE AVE
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City | NILES
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State | IL
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Zip | 60714-1116
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Country | US
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Telephone | 847-965-3791
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Fax | 847-965-3947
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Authorized Official
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Title or Position | OD
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Name | DR. DANIEL MEDEMA
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Credential |
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Telephone | 847-965-3791
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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 | 046008031
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License Number State | IL
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