MEDICARE: ID

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	152W00000X	Optometrist	047.931688	IL

General Provider Information

NPI Number	:	1548384449
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ID

Provider Business Mailing Address
First Line	:	2130 N DAMEN
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647
Country	:	US
Telephone Number	:	773-755-4343
Fax Number	:	312-929-2376

Provider Business Practice Location Address
First Line	:	2130 N DAMEN
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647
Country	:	US
Telephone Number	:	773-755-4343
Fax Number	:	312-929-2376

Authorized Official
Title or Position	:	CFO
Name	:	ANTHONY ALMAGUER
Credential	:
Telephone Number	:	773-755-4343

Provider Enumeration Date	:	03/17/2007
Last Update Date	:	11/03/2017

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