MEDICARE: MR. TEODORO CARRILLO OPTICIAN

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	2511-5278	IL

General Provider Information

NPI Number	:	1962528372
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TEODORO CARRILLO OPTICIAN

Provider Business Mailing Address
First Line	:	4610 N LINCOLN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-2008
Country	:	US
Telephone Number	:	773-561-0870
Fax Number	:	773-561-4185

Provider Business Practice Location Address
First Line	:	4610 N LINCOLN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-2008
Country	:	US
Telephone Number	:	773-561-0870
Fax Number	:	773-561-4185

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/21/2007
Last Update Date	:	02/29/2016

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