MEDICARE: JACK SHAW SUPERIOR EYE CARE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	156FX1800X	Optician

General Provider Information

NPI Number	:	1104040328
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JACK SHAW SUPERIOR EYE CARE

Provider Business Mailing Address
First Line	:	2906 N BROADWAY ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-7163
Country	:	US
Telephone Number	:	773-525-1601
Fax Number	:	773-435-4210

Provider Business Practice Location Address
First Line	:	2906 N BROADWAY ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-7163
Country	:	US
Telephone Number	:	773-525-1601
Fax Number	:	773-435-4210

Authorized Official
Title or Position	:	OWNER
Name	:	MR. JACK SHAW
Credential	:	OPTICIAN
Telephone Number	:	773-525-1601

Provider Enumeration Date	:	04/11/2007
Last Update Date	:	08/19/2015

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