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General NPI Number Information
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NPI Number | 1881264141
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Entity Type | Organization
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Legal Business Name | RANDALL R RICKETTS OD LLC
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Dates
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Enumeration Date | 06/29/2021
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Last Update Date | 04/15/2025
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Provider Practice Location Address
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Address Line | 2338 N CLARK ST
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City | CHICAGO
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State | IL
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Zip | 60614-7043
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Country | US
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Telephone | 773-857-1260
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Fax | 773-857-1624
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Provider Business Mailing Address
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Address Line | 1133 W PRATT BLVD APT 1
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City | CHICAGO
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State | IL
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Zip | 60626-6781
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Country | US
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Telephone | 773-857-1260
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Fax | 773-857-1640
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Authorized Official
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Title or Position | BUSINESS MANAGER
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Name | JAMIE ALEXAKOS
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Credential |
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Telephone | 773-857-1260
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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 |
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License Number State |
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