1154552016 NPI number — CRYSTAL CLEAR EYE CARE CLINIC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154552016 NPI number — CRYSTAL CLEAR EYE CARE CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CRYSTAL CLEAR EYE CARE CLINIC
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:
1154552016
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/26/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1760 WISE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SCHAUMBERG
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60193
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-524-1700
Provider Business Mailing Address Fax Number:
847-524-1702

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1760 WISE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SCHAUMBERG
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60193
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-524-1700
Provider Business Practice Location Address Fax Number:
847-524-1702
Provider Enumeration Date:
07/27/2009

Additional Information

Authorized Official

Authorized Official Last Name:
BAKOVICH
Authorized Official First Name:
SHERRY
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OFFICE MANGER
Authorized Official Telephone Number:
847-524-1700

Provider Taxonomy Codes

  • Taxonomy code: 305R00000X , with the licence number:  047935456 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 305R00000X , with the licence number: 046007080 , 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: 1730125451 . This is a "NPI" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 1841370061 . This is a "NPI" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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