Provider Demographics
NPI:1114144276
Name:EYE BOUTIQUE INC
Entity Type:Organization
Organization Name:EYE BOUTIQUE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DARREN
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:HORNDASCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-432-2005
Mailing Address - Street 1:16800 W CLEVELAND AVE
Mailing Address - Street 2:
Mailing Address - City:NEW BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53151-3533
Mailing Address - Country:US
Mailing Address - Phone:262-432-2005
Mailing Address - Fax:262-432-2006
Practice Address - Street 1:1839 W IRVING PARK RD
Practice Address - Street 2:
Practice Address - City:SCHAUMBURG
Practice Address - State:IL
Practice Address - Zip Code:60193-3509
Practice Address - Country:US
Practice Address - Phone:847-891-9096
Practice Address - Fax:262-923-7670
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No332H00000XSuppliersEyewear SupplierGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6172600006Medicare NSC