=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699802421
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE EYE SPECIALISTS CENTER, L.L.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/28/2007
-----------------------------------------------------
Last Update Date | 04/30/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10436 SOUTHWEST HWY
-----------------------------------------------------
City | CHICAGO RIDGE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60415-2282
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-423-4070
-----------------------------------------------------
Fax | 708-423-4216
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | DEPARTMENT 4684
-----------------------------------------------------
City | CAROL STREAM
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60122-4684
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-952-0109
-----------------------------------------------------
Fax | 708-952-0329
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PARTNER/PHYSICIAN
-----------------------------------------------------
Name | DR. BENJAMIN HENDRICK TICHO
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 708-423-4070
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 156FX1202X
-----------------------------------------------------
Taxonomy Name | Optometric Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------