Basic Information
| Provider Information | |||||||||
| NPI: | 1053621391 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EYAS LANDING, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1409 W CARROLL AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606071105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3127330883 | ||||||||
| FaxNumber: | 3122531440 | ||||||||
| Practice Location | |||||||||
| Address1: | 1409 W CARROLL AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606071105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3127330883 | ||||||||
| FaxNumber: | 3122531440 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2010 | ||||||||
| LastUpdateDate: | 09/01/2022 | ||||||||
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| AuthorizedOfficialLastName: | MRAZ | ||||||||
| AuthorizedOfficialFirstName: | LAURA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3127330883 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | OTD | ||||||||
| NPICertificationDate: | 08/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251C00000X | N | Agencies | Day Training, Developmentally Disabled Services | 252Y00000X | 056009137 | IL | Y | Agencies | Early Intervention Provider Agency |
No ID Information.