Provider Demographics
NPI:1366043382
Name:GLEN ELLYN FAMILY EYE CARE LLC
Entity Type:Organization
Organization Name:GLEN ELLYN FAMILY EYE CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TOM
Authorized Official - Middle Name:
Authorized Official - Last Name:PANOS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:708-710-0005
Mailing Address - Street 1:510 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GLEN ELLYN
Mailing Address - State:IL
Mailing Address - Zip Code:60137-5104
Mailing Address - Country:US
Mailing Address - Phone:630-858-3937
Mailing Address - Fax:
Practice Address - Street 1:510 N MAIN ST
Practice Address - Street 2:
Practice Address - City:GLEN ELLYN
Practice Address - State:IL
Practice Address - Zip Code:60137-5104
Practice Address - Country:US
Practice Address - Phone:630-858-3937
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-05
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty