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General NPI Number Information
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NPI Number | 1801265657
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Entity Type | Organization
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Legal Business Name | EVANSTON EYE WELLNESS INC.
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Dates
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Enumeration Date | 09/23/2015
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Last Update Date | 01/08/2016
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Provider Practice Location Address
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Address Line | 716 MAIN ST
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City | EVANSTON
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State | IL
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Zip | 60202-1816
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Country | US
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Telephone | 847-350-7952
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Fax | 847-929-9764
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Provider Business Mailing Address
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Address Line | 716 MAIN ST
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City | EVANSTON
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State | IL
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Zip | 60202-1816
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Country | US
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Telephone | 847-350-7952
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Fax | 847-929-9764
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. DEANA LABROSSE
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Credential | O.D.
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Telephone | 847-350-7952
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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 | 046009750
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License Number State | IL
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