MEDICARE: INDUSTRIAL OPTICAL SERVICE, 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	152W00000X	Optometrist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1636706	OTHER		BCBS
2	7235044	OTHER		AETNA

General Provider Information

NPI Number	:	1770884488
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INDUSTRIAL OPTICAL SERVICE, INC

Provider Business Mailing Address
First Line	:	115 S LASALLE ST
Second Line	:	27TH FLOOR
City	:	CHICAGO
State	:	IL
Zip	:	60603-3801
Country	:	US
Telephone Number	:	312-673-7192
Fax Number	:

Provider Business Practice Location Address
First Line	:	3760 N BROADWAY ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-4105
Country	:	US
Telephone Number	:	773-975-2020
Fax Number	:

Authorized Official
Title or Position	:	OPOMETRIST
Name	:	CARRIE ROITSTEIN
Credential	:	O.D.
Telephone Number	:	312-673-7192

Provider Enumeration Date	:	11/11/2010
Last Update Date	:	02/07/2011

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Directions to “INDUSTRIAL OPTICAL SERVICE, INC ” Practice Location

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