1881971133 NPI number — THIRD STREET EYECARE, LTD

Table of content: (NPI 1881971133)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881971133 NPI number — THIRD STREET EYECARE, LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THIRD STREET EYECARE, LTD
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:
1881971133
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3317 HUSKING PEG LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GENEVA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60134-4656
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-751-5269
Provider Business Mailing Address Fax Number:
331-248-0328

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 S THIRD ST
Provider Second Line Business Practice Location Address:
STE 105
Provider Business Practice Location Address City Name:
GENEVA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60134-2762
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-751-5269
Provider Business Practice Location Address Fax Number:
331-248-0328
Provider Enumeration Date:
11/14/2011

Additional Information

Authorized Official

Authorized Official Last Name:
BURGGRAF
Authorized Official First Name:
RANDALL
Authorized Official Middle Name:
D
Authorized Official Title or Position:
DOCTOR
Authorized Official Telephone Number:
815-751-5269

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  00466713 , 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: 1447318563 . This is a "INDIVIDUAL NPI" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 046006713 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com