1699943316 NPI number — LOTUS EYECARE, INC.

Table of content: (NPI 1699943316)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699943316 NPI number — LOTUS EYECARE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LOTUS EYECARE, 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:
WICKER PARK EYE CENTER
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:
1699943316
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/12/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2222 W DIVISION ST
Provider Second Line Business Mailing Address:
SUITE 135
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60622-2717
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-376-2020
Provider Business Mailing Address Fax Number:
773-376-2227

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2222 W DIVISION ST
Provider Second Line Business Practice Location Address:
SUITE 135
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60622-2717
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-376-2020
Provider Business Practice Location Address Fax Number:
773-376-2227
Provider Enumeration Date:
02/15/2008

Additional Information

Authorized Official

Authorized Official Last Name:
TEPPER
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
773-376-2020

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  IL0 36096708 , 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: 036096708 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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