Basic Information
| Provider Information | |||||||||
| NPI: | 1467181040 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LARGE | ||||||||
| FirstName: | MACKENZIE | ||||||||
| MiddleName: | KATHRYN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 7288 174TH PL | ||||||||
| Address2: | |||||||||
| City: | TINLEY PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604773214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7082853321 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4541 211TH ST | ||||||||
| Address2: | |||||||||
| City: | MATTESON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604432318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084811534 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2022 | ||||||||
| LastUpdateDate: | 06/08/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 046.011618 | IL | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.