Provider Demographics
NPI:1053857078
Name:STOCKMASTER ENTERPRISES INC
Entity Type:Organization
Organization Name:STOCKMASTER ENTERPRISES INC
Other - Org Name:EYE CARE AT HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KRYSTLE
Authorized Official - Middle Name:J
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:708-770-6404
Mailing Address - Street 1:9750 CRESCENT PARK CIR
Mailing Address - Street 2:243
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-7540
Mailing Address - Country:US
Mailing Address - Phone:708-770-6404
Mailing Address - Fax:
Practice Address - Street 1:9750 CRESCENT PARK CIR
Practice Address - Street 2:243
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-7540
Practice Address - Country:US
Practice Address - Phone:708-770-6404
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-13
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046010696152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1578998936Medicaid