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General NPI Number Information
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NPI Number | 1881971133
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Entity Type | Organization
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Legal Business Name | THIRD STREET EYECARE, LTD
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Dates
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Enumeration Date | 11/14/2011
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Last Update Date | 03/07/2023
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Provider Practice Location Address
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Address Line | 500 S THIRD ST STE 105
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City | GENEVA
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State | IL
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Zip | 60134-2762
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Country | US
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Telephone | 815-751-5269
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Fax | 331-248-0328
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Provider Business Mailing Address
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Address Line | 3317 HUSKING PEG LN
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City | GENEVA
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State | IL
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Zip | 60134-4656
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Country | US
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Telephone | 815-751-5269
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Fax | 331-248-0328
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Authorized Official
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Title or Position | DOCTOR
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Name | DR. RANDALL D BURGGRAF
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Credential | OD
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Telephone | 815-751-5269
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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 | 00466713
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License Number State | IL
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