Provider Demographics
NPI:1346384450
Name:MODERN OPTICAL EYEWEAR, INC.
Entity Type:Organization
Organization Name:MODERN OPTICAL EYEWEAR, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:MANIATAKIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-784-6300
Mailing Address - Street 1:2812 W FOSTER AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-3506
Mailing Address - Country:US
Mailing Address - Phone:773-784-6300
Mailing Address - Fax:773-360-9589
Practice Address - Street 1:2812 W FOSTER AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-3506
Practice Address - Country:US
Practice Address - Phone:773-784-6300
Practice Address - Fax:773-360-9589
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2008-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL332H00000X332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0722440001Medicare NSC