Provider Demographics
NPI:1205225570
Name:WOOLDRIDGE, PC
Entity Type:Organization
Organization Name:WOOLDRIDGE, PC
Other - Org Name:CORNER EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:COUNT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-998-4737
Mailing Address - Street 1:1005 HARLEM AVE
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60025-2935
Mailing Address - Country:US
Mailing Address - Phone:847-998-4737
Mailing Address - Fax:847-998-4760
Practice Address - Street 1:1005 HARLEM AVE
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60025-2935
Practice Address - Country:US
Practice Address - Phone:847-998-4737
Practice Address - Fax:847-998-4760
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-09
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046010737152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400095688Medicare PIN