=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790486207
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCED EYECARE OF HANOVER PARK, CORP.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/13/2023
-----------------------------------------------------
Last Update Date | 02/21/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1156 E LAKE ST
-----------------------------------------------------
City | HANOVER PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60133-5421
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-855-5542
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1325 N MAIN ST
-----------------------------------------------------
City | WHEATON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60187-3579
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-668-4144
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | GRISHMA P PATEL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 630-855-5542
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------