Provider Demographics
NPI:1104040328
Name:JACK SHAW SUPERIOR EYE CARE
Entity Type:Organization
Organization Name:JACK SHAW SUPERIOR EYE CARE
Other - Org Name:SUPERIOR EYE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAW
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:773-525-1601
Mailing Address - Street 1:2906 N BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-7163
Mailing Address - Country:US
Mailing Address - Phone:773-525-1601
Mailing Address - Fax:773-435-4210
Practice Address - Street 1:2906 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-7163
Practice Address - Country:US
Practice Address - Phone:773-525-1601
Practice Address - Fax:773-435-4210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty