Provider Demographics
NPI:1033442769
Name:SYPHERD OPTICAL INC.
Entity Type:Organization
Organization Name:SYPHERD OPTICAL INC.
Other - Org Name:CARRIE SYPHERD, OD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:CARRIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SYPHERD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:815-455-2800
Mailing Address - Street 1:820 E. TERRA COTTA AVE. SUITE 256
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014
Mailing Address - Country:US
Mailing Address - Phone:815-455-2800
Mailing Address - Fax:815-455-2801
Practice Address - Street 1:26W171 ROOSEVELT ROAD
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187
Practice Address - Country:US
Practice Address - Phone:815-455-2800
Practice Address - Fax:815-455-2801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-14
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL047931297152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL 2607Medicare PIN
ILIL 2605Medicare PIN
IL211827Medicare PIN
ILDQ4908Medicare PIN