Provider Demographics
NPI:1376677971
Name:ADVANCED FOCUS VISION CENTER LTD.
Entity Type:Organization
Organization Name:ADVANCED FOCUS VISION CENTER LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOUTON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:815-467-0077
Mailing Address - Street 1:24735 W EAMES ST
Mailing Address - Street 2:SUITE 11
Mailing Address - City:CHANNAHON
Mailing Address - State:IL
Mailing Address - Zip Code:60410-8705
Mailing Address - Country:US
Mailing Address - Phone:815-467-0077
Mailing Address - Fax:815-467-0088
Practice Address - Street 1:24735 W EAMES ST
Practice Address - Street 2:SUITE 11
Practice Address - City:CHANNAHON
Practice Address - State:IL
Practice Address - Zip Code:60410-8705
Practice Address - Country:US
Practice Address - Phone:815-467-0077
Practice Address - Fax:815-467-0088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2009-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-009118152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL215837Medicare PIN
ILU72940Medicare UPIN
IL1154375392Medicare ID - Type UnspecifiedNPI FOR EMPLOYMENT