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General NPI Number Information
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NPI Number | 1851459481
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Entity Type | Organization
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Legal Business Name | LA VALLEE OPTOMETRIC LTD.
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Dates
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Enumeration Date | 12/05/2006
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Last Update Date | 09/29/2008
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Provider Practice Location Address
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Address Line | 2111 W SUPERIOR ST
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City | CHICAGO
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State | IL
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Zip | 60612-1315
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Country | US
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Telephone | 773-895-3411
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Fax | 312-226-0802
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Provider Business Mailing Address
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Address Line | 2111 W SUPERIOR ST
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City | CHICAGO
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State | IL
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Zip | 60612-1315
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Country | US
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Telephone | 773-895-3411
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Fax | 312-226-0802
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. KEITH LA VALLEE
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Credential | O.D.
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Telephone | 773-895-3411
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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 | 046009075
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License Number State | IL
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