1598762007 NPI number — OLYMPIA FIELDS EYECARE, LTD.

Table of content: (NPI 1598762007)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598762007 NPI number — OLYMPIA FIELDS EYECARE, LTD.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OLYMPIA FIELDS EYECARE, LTD.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1598762007
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/09/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19740 GOVERNORS HWY STE 124
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLOSSMOOR
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60422-2085
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-957-1618
Provider Business Mailing Address Fax Number:
708-748-7305

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19740 GOVERNORS HWY STE 124
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLOSSMOOR
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60422-2085
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-748-5202
Provider Business Practice Location Address Fax Number:
708-748-7305
Provider Enumeration Date:
06/30/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BURKE
Authorized Official First Name:
SHARON
Authorized Official Middle Name:
S.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
708-957-1618

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  042007134 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 036078950 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".