Provider Demographics
NPI:1467483941
Name:LAKESIDE EYE CARE & EYE WEAR EMPORIUM, LTD.
Entity Type:Organization
Organization Name:LAKESIDE EYE CARE & EYE WEAR EMPORIUM, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NADER
Authorized Official - Middle Name:E
Authorized Official - Last Name:FAKHOURY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:847-864-9393
Mailing Address - Street 1:1605 BENSON AVENUE
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201
Mailing Address - Country:US
Mailing Address - Phone:847-864-9393
Mailing Address - Fax:
Practice Address - Street 1:1605 BENSON AVENUE
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201
Practice Address - Country:US
Practice Address - Phone:847-864-9393
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL214279Medicare ID - Type UnspecifiedGROUP NUMBER