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General NPI Number Information
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NPI Number | 1861643355
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Entity Type | Organization
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Legal Business Name | PROFESSIONAL EYE CARE
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Dates
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Enumeration Date | 10/02/2008
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Last Update Date | 11/20/2008
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Provider Practice Location Address
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Address Line | 2017 75TH ST
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City | WOODRIDGE
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State | IL
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Zip | 60517-2308
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Country | US
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Telephone | 630-427-1000
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Fax | 630-427-1280
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Provider Business Mailing Address
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Address Line | 2017 75TH ST
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City | WOODRIDGE
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State | IL
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Zip | 60517-2308
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Country | US
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Telephone | 630-427-1000
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Fax | 630-427-1280
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Authorized Official
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Title or Position | OWNER
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Name | DR. SRINIVAS JAIRAM
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Credential | OD
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Telephone | 630-427-1000
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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 | 047.106798
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License Number State | IL
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