1770712531 NPI number — ADVANCED EYE CARE SC

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 1770712531 NPI number — ADVANCED EYE CARE SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCED EYE CARE 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:
1770712531
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/27/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1870 SILVER CROSS BOULEVARD
Provider Second Line Business Mailing Address:
SUITE110
Provider Business Mailing Address City Name:
NEW LENOX
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60451
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-485-2727
Provider Business Mailing Address Fax Number:
815-485-3034

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1870 SILVER CROSS BOULEVARD
Provider Second Line Business Practice Location Address:
SUITE110
Provider Business Practice Location Address City Name:
NEW LENOX
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60451
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-485-2727
Provider Business Practice Location Address Fax Number:
815-485-3034
Provider Enumeration Date:
07/14/2009

Additional Information

Authorized Official

Authorized Official Last Name:
KISLA
Authorized Official First Name:
TIMOTHY
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
815-485-2727

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  042618144 , 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)





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