Provider Demographics
NPI:1215204169
Name:BLANCO KAYS CORGIAT EYECARE, LLC
Entity Type:Organization
Organization Name:BLANCO KAYS CORGIAT EYECARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:PARTRIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-663-8281
Mailing Address - Street 1:200 W DAKOTA ST
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:IL
Mailing Address - Zip Code:61362-1906
Mailing Address - Country:US
Mailing Address - Phone:815-663-8281
Mailing Address - Fax:
Practice Address - Street 1:200 W DAKOTA ST
Practice Address - Street 2:
Practice Address - City:SPRING VALLEY
Practice Address - State:IL
Practice Address - Zip Code:61362-1906
Practice Address - Country:US
Practice Address - Phone:815-663-8281
Practice Address - Fax:815-663-8190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-21
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046006809152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6643640001Medicare NSC
ILIL6520Medicare PIN
ILDS4037Medicare PIN