=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851441968
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INDUSTRIAL OPTICAL SERVICE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/11/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2316 N CLARK ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60614-7760
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-404-0777
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4418 W DIVERSEY AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60639-1924
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST
-----------------------------------------------------
Name | CARRIE B ROITSTEIN
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 773-404-0777
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------