Provider Demographics
NPI:1306004148
Name:FORECKI, DIANE G (OD)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:G
Last Name:FORECKI
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 W NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:NORTHLAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60164-2316
Mailing Address - Country:US
Mailing Address - Phone:708-409-0047
Mailing Address - Fax:
Practice Address - Street 1:137 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:NORTHLAKE
Practice Address - State:IL
Practice Address - Zip Code:60164-2316
Practice Address - Country:US
Practice Address - Phone:708-409-0047
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-29
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046007557152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist