Provider Demographics
NPI:1114965126
Name:INTERSTATE OPTICAL LBR INC
Entity Type:Organization
Organization Name:INTERSTATE OPTICAL LBR INC
Other - Org Name:MARQUETTE VISION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:STEPHENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-479-6232
Mailing Address - Street 1:9612 WILLOW LN
Mailing Address - Street 2:
Mailing Address - City:MOKENA
Mailing Address - State:IL
Mailing Address - Zip Code:60448-9318
Mailing Address - Country:US
Mailing Address - Phone:708-479-6232
Mailing Address - Fax:
Practice Address - Street 1:9612 WILLOW LN
Practice Address - Street 2:
Practice Address - City:MOKENA
Practice Address - State:IL
Practice Address - Zip Code:60448-9318
Practice Address - Country:US
Practice Address - Phone:708-479-6232
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-02
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0152900001Medicare ID - Type Unspecified