Provider Demographics
NPI:1275802605
Name:ADVANCED FAMILY EYECARE CENTER OF BOLINGBROOK,INC.
Entity Type:Organization
Organization Name:ADVANCED FAMILY EYECARE CENTER OF BOLINGBROOK,INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:SUBAK
Authorized Official - Suffix:JR
Authorized Official - Credentials:OD
Authorized Official - Phone:630-759-6506
Mailing Address - Street 1:13165 RAPHAEL ST
Mailing Address - Street 2:
Mailing Address - City:LEMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60439-9164
Mailing Address - Country:US
Mailing Address - Phone:630-759-6506
Mailing Address - Fax:630-759-6651
Practice Address - Street 1:480 W BOUGHTON RD
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-1890
Practice Address - Country:US
Practice Address - Phone:630-759-6506
Practice Address - Fax:630-759-6651
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-13
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-007833152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL6779Medicare PIN
ILDS7665Medicare PIN