1356403919 NPI number — CAREN LYNN WEISZ

Table of content: (NPI 1356403919)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356403919 NPI number — CAREN LYNN WEISZ

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CAREN LYNN WEISZ
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:
PEDIATRIC OPTOMETRY ASSOCIATES
Provider Other Organization Name Type Code:
3
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:
1356403919
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1520 ROCK RUN DRIVE
Provider Second Line Business Mailing Address:
SUITE 2
Provider Business Mailing Address City Name:
CREST HILL
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60403-3153
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-744-6735
Provider Business Mailing Address Fax Number:
815-744-6703

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1520 ROCK RUN DRIVE
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
CREST HILL
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60403-3153
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-744-6735
Provider Business Practice Location Address Fax Number:
815-744-6703
Provider Enumeration Date:
12/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WEISZ
Authorized Official First Name:
CAREN
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
815-744-6735

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , 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: 03574 . This is a "SPECTERA" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 115683 . This is a "EYEMED" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 3120 . This is a "DAVIS VISION" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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