Basic Information
| Provider Information | |||||||||
| NPI: | 1639229776 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INDUSTRIAL OPTICAL SERVICE, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | VILLAGE VISION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4418 W DIVERSEY AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606391924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7737366800 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 146 CENTER ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | GRAYSLAKE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600301533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7737366800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2007 | ||||||||
| LastUpdateDate: | 05/15/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LIEBERMAN | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7737366800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | O.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 7235044 | 01 | IL | AETNA | OTHER | 1636706 | 01 | IL | BCBS | OTHER |