1043225535 NPI number — EYES OF GRACE SC

Table of content: (NPI 1043225535)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043225535 NPI number — EYES OF GRACE SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EYES OF GRACE SC
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:
1043225535
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/12/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5178
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SKOKIE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60076-5178
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-933-3555
Provider Business Mailing Address Fax Number:
847-933-3559

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9669 KENTON AVE STE 409
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SKOKIE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60076-1267
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-933-0800
Provider Business Practice Location Address Fax Number:
855-329-4224
Provider Enumeration Date:
07/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BAI
Authorized Official First Name:
GRACE
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
847-933-0800

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 036103366 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01633731 . This is a "BS OF IL" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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