MEDICARE: INTERSTATE OPTICAL LBR INC

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	:	1114965126
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTERSTATE OPTICAL LBR INC

Provider Business Mailing Address
First Line	:	9612 WILLOW LN
Second Line	:
City	:	MOKENA
State	:	IL
Zip	:	60448-9318
Country	:	US
Telephone Number	:	708-479-6232
Fax Number	:

Provider Business Practice Location Address
First Line	:	9612 WILLOW LN
Second Line	:
City	:	MOKENA
State	:	IL
Zip	:	60448-9318
Country	:	US
Telephone Number	:	708-479-6232
Fax Number	:

Authorized Official
Title or Position	:	OPTICIAN
Name	:	MR. GARY LEE STEPHENS
Credential	:
Telephone Number	:	708-479-6232

Provider Enumeration Date	:	06/02/2006
Last Update Date	:	10/19/2007

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Directions to “INTERSTATE OPTICAL LBR INC ” Practice Location

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