Provider Demographics
NPI:1114458072
Name:TWO NON-BLONDES, LLC
Entity Type:Organization
Organization Name:TWO NON-BLONDES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ANITA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:224-676-1022
Mailing Address - Street 1:2013 MILWAUKEE AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERWOODS
Mailing Address - State:IL
Mailing Address - Zip Code:60015-3581
Mailing Address - Country:US
Mailing Address - Phone:224-676-1022
Mailing Address - Fax:
Practice Address - Street 1:2013 MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:RIVERWOODS
Practice Address - State:IL
Practice Address - Zip Code:60015-3581
Practice Address - Country:US
Practice Address - Phone:224-676-1022
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-22
Last Update Date:2017-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046.010088152W00000X
IL046.010749152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046.010088Medicaid