Provider Demographics
NPI:1114305943
Name:ILLINIEYE INC
Entity Type:Organization
Organization Name:ILLINIEYE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:YEVGENY
Authorized Official - Middle Name:
Authorized Official - Last Name:GRINMAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:847-394-2255
Mailing Address - Street 1:1119 MOUNT PROSPECT PLZ
Mailing Address - Street 2:
Mailing Address - City:MT PROSPECT
Mailing Address - State:IL
Mailing Address - Zip Code:60056-2653
Mailing Address - Country:US
Mailing Address - Phone:847-394-2255
Mailing Address - Fax:
Practice Address - Street 1:1119 MOUNT PROSPECT PLZ
Practice Address - Street 2:
Practice Address - City:MT PROSPECT
Practice Address - State:IL
Practice Address - Zip Code:60056-2653
Practice Address - Country:US
Practice Address - Phone:847-394-2255
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-13
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046009751152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty