Provider Demographics
NPI:1215040142
Name:ILLIANA EYECARE INC
Entity Type:Organization
Organization Name:ILLIANA EYECARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JILL
Authorized Official - Middle Name:S
Authorized Official - Last Name:DAVIDS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:219-669-1012
Mailing Address - Street 1:13115 WICKER AVENUE
Mailing Address - Street 2:SUITE E
Mailing Address - City:CEDAR LAKE
Mailing Address - State:IN
Mailing Address - Zip Code:46303
Mailing Address - Country:US
Mailing Address - Phone:219-374-7800
Mailing Address - Fax:
Practice Address - Street 1:13115 WICKER AVENUE
Practice Address - Street 2:SUITE E
Practice Address - City:CEDAR LAKE
Practice Address - State:IN
Practice Address - Zip Code:46303
Practice Address - Country:US
Practice Address - Phone:219-374-7800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN046009654152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN248540BMedicare UPIN
IN248540AMedicare UPIN
IN5857410001Medicare NSC
IN248540Medicare PIN
ILV01818Medicare UPIN
IN5857410001Medicare PIN