Provider Demographics
NPI:1477995074
Name:EDGEBROOK VISION CENTER LLC
Entity Type:Organization
Organization Name:EDGEBROOK VISION CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:ROSEMARY
Authorized Official - Middle Name:THERESA
Authorized Official - Last Name:KAFKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-550-9667
Mailing Address - Street 1:5315 W DEVON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60646-4107
Mailing Address - Country:US
Mailing Address - Phone:773-775-6555
Mailing Address - Fax:773-775-3350
Practice Address - Street 1:5315 W DEVON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60646-4107
Practice Address - Country:US
Practice Address - Phone:773-775-6555
Practice Address - Fax:773-775-3350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-24
Last Update Date:2013-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier