MEDICARE: SIX CORNERS EYE CARE LLC

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

General Provider Information

NPI Number	:	1629899141
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SIX CORNERS EYE CARE LLC

Provider Business Mailing Address
First Line	:	2501 CHATHAM RD STE R
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62704-4188
Country	:	US
Telephone Number	:	832-607-2055
Fax Number	:

Provider Business Practice Location Address
First Line	:	4017 N MILWAUKEE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60641-1834
Country	:	US
Telephone Number	:	773-545-2660
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	TAJAL PATEL DARNE
Credential	:	OD
Telephone Number	:	832-607-2055

Provider Enumeration Date	:	10/17/2024
Last Update Date	:	01/14/2025

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