Basic Information
| Provider Information | |||||||||
| NPI: | 1972597342 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GM REVELLE INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | VISION GALLERY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2820 PLAINFIELD RD | ||||||||
| Address2: | |||||||||
| City: | JOLIET | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604351167 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8154361144 | ||||||||
| FaxNumber: | 8154361260 | ||||||||
| Practice Location | |||||||||
| Address1: | 2820 PLAINFIELD RD | ||||||||
| Address2: | |||||||||
| City: | JOLIET | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604351167 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8154361144 | ||||||||
| FaxNumber: | 8154361260 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2005 | ||||||||
| LastUpdateDate: | 04/30/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DETTMANN | ||||||||
| AuthorizedOfficialFirstName: | DENNIS | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8154361144 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | O.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 046007054 | 05 | IL | MEDICAID | 9932299 | 01 | IL | BC/BS | OTHER |