Provider Demographics
NPI:1447595780
Name:MALIK EYE INSTITUTE LLC
Entity Type:Organization
Organization Name:MALIK EYE INSTITUTE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:RANAE
Authorized Official - Middle Name:D
Authorized Official - Last Name:BERGMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-399-2190
Mailing Address - Street 1:4857 MANHATTAN DR
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-2265
Mailing Address - Country:US
Mailing Address - Phone:815-399-0599
Mailing Address - Fax:815-399-2499
Practice Address - Street 1:4857 MANHATTAN DR
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2265
Practice Address - Country:US
Practice Address - Phone:815-399-0599
Practice Address - Fax:815-399-5543
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-27
Last Update Date:2013-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-110588332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6725940001OtherPTAN