1659529436 NPI number — EYE BOUTIQUE INC

Table of content: (NPI 1659529436)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659529436 NPI number — EYE BOUTIQUE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EYE BOUTIQUE INC
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:
1659529436
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16800 W CLEVELAND AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW BERLIN
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53151-3533
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-432-2005
Provider Business Mailing Address Fax Number:
262-432-2006

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1273 S NAPER BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NAPERVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60540-8300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-369-8098
Provider Business Practice Location Address Fax Number:
262-923-7672
Provider Enumeration Date:
09/04/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HORNDASCH
Authorized Official First Name:
DARREN
Authorized Official Middle Name:
THOMAS
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
262-432-2005

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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