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General NPI Number Information
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NPI Number | 1932288198
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Entity Type | Organization
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Legal Business Name | CHARLES S KEFALAS ODPC
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Dates
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Enumeration Date | 11/06/2006
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Last Update Date | 07/19/2010
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Provider Practice Location Address
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Address Line | 4256 W 63RD ST
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City | CHICAGO
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State | IL
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Zip | 60629-5037
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Country | US
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Telephone | 773-582-0660
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Fax | 773-582-0859
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Provider Business Mailing Address
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Address Line | 4256 W 63RD ST
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City | CHICAGO
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State | IL
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Zip | 60629-5037
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Country | US
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Telephone | 773-582-0660
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Fax | 773-582-0859
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. CHARLES S KEFALAS
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Credential | OD
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Telephone | 773-582-0660
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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 | 046008568
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License Number State | IL
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