Provider Demographics
NPI:1346390499
Name:INDUSTRIAL OPTICAL SERVICE, INC.
Entity Type:Organization
Organization Name:INDUSTRIAL OPTICAL SERVICE, INC.
Other - Org Name:EYELAND OF ST. JOHNS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:LIEBERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:773-736-6800
Mailing Address - Street 1:4418 W DIVERSEY AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60639-1924
Mailing Address - Country:US
Mailing Address - Phone:773-736-6800
Mailing Address - Fax:
Practice Address - Street 1:507 S 3RD ST
Practice Address - Street 2:SUITE F
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-2730
Practice Address - Country:US
Practice Address - Phone:630-397-5900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1636706OtherBCBS
IL7235044OtherAETNA
IL1636706OtherBCBS