Basic Information
| Provider Information | |||||||||
| NPI: | 1982017851 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MACCI | ||||||||
| FirstName: | TEHNEIYAT | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 152 S BLOOMINGDALE RD | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGDALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601081481 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6309804446 | ||||||||
| FaxNumber: | 6309802313 | ||||||||
| Practice Location | |||||||||
| Address1: | 152 S BLOOMINGDALE RD | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGDALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601081481 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6309804446 | ||||||||
| FaxNumber: | 6309802313 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2014 | ||||||||
| LastUpdateDate: | 01/27/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 046010772 | IL | N | Eye and Vision Services Providers | Optometrist | 152WC0802X | 046.010772 | IL | N | Eye and Vision Services Providers | Optometrist | Corneal and Contact Management | 152WP0200X | 046.010772 | IL | N | Eye and Vision Services Providers | Optometrist | Pediatrics | 152W00000X | 046.010772 | IL | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.