1992982169 NPI number — LORETTA DE KOSTER,O.D. INC.

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 1992982169 NPI number — LORETTA DE KOSTER,O.D. INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LORETTA DE KOSTER,O.D. 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:
MELROSE EYECARE 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:
1992982169
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/15/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2528 N HARLEM AVE
Provider Second Line Business Mailing Address:
MAIN FLOOR
Provider Business Mailing Address City Name:
ELMWOOD PARK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60707-2046
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-456-4362
Provider Business Mailing Address Fax Number:
708-456-5161

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2528 N HARLEM AVE
Provider Second Line Business Practice Location Address:
MAIN FLOOR
Provider Business Practice Location Address City Name:
ELMWOOD PARK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60707-2046
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-456-4362
Provider Business Practice Location Address Fax Number:
708-456-5161
Provider Enumeration Date:
01/30/2008

Additional Information

Authorized Official

Authorized Official Last Name:
DE KOSTER
Authorized Official First Name:
LORETTA
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
708-456-4362

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  046008683 , 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: 01621057 . This is a "BCBS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 046008683 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: IL4407 . This is a "MEDICARE PTAN" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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