MEDICARE: DEKALB EYE CONSULTANTS, 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	:	1952809782
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DEKALB EYE CONSULTANTS, LLC

Provider Business Mailing Address
First Line	:	1630 GATEWAY DR
Second Line	:
City	:	SYCAMORE
State	:	IL
Zip	:	60178-3182
Country	:	US
Telephone Number	:	815-756-8571
Fax Number	:	815-756-5603

Provider Business Practice Location Address
First Line	:	3711 W LAWRENCE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-5712
Country	:	US
Telephone Number	:	773-583-5727
Fax Number	:	773-583-7768

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	GEORGE L NEAL
Credential	:
Telephone Number	:	469-214-0144

Provider Enumeration Date	:	01/26/2018
Last Update Date	:	02/05/2020

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