Basic Information
| Provider Information | |||||||||
| NPI: | 1467918854 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VAN | ||||||||
| FirstName: | KHAI | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8535 MENARD AVE | ||||||||
| Address2: | |||||||||
| City: | BURBANK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604592660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7736270223 | ||||||||
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| Practice Location | |||||||||
| Address1: | 16205 HARLEM AVE STE B | ||||||||
| Address2: | |||||||||
| City: | TINLEY PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604771682 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7086149301 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/11/2019 | ||||||||
| LastUpdateDate: | 02/11/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 046.011264 | IL | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.