Provider Demographics
NPI:1386192219
Name:LUMEN OPTICAL ILLINOIS 2, LLC
Entity Type:Organization
Organization Name:LUMEN OPTICAL ILLINOIS 2, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRIVACY OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-316-5508
Mailing Address - Street 1:809 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-3706
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:809 CHURCH ST
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-3706
Practice Address - Country:US
Practice Address - Phone:801-316-5508
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-20
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Single Specialty
No152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Single Specialty
No152WX0102XEye and Vision Services ProvidersOptometristOccupational VisionGroup - Single Specialty
No156F00000XEye and Vision Services ProvidersTechnician/TechnologistGroup - Single Specialty
No156FC0800XEye and Vision Services ProvidersTechnician/TechnologistContact LensGroup - Single Specialty
No156FC0801XEye and Vision Services ProvidersTechnician/TechnologistContact Lens FitterGroup - Single Specialty
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty