Provider Demographics
NPI:1538466560
Name:DIABETIC EYE CENTERS OF AMERICA, INCORPORATED
Entity Type:Organization
Organization Name:DIABETIC EYE CENTERS OF AMERICA, INCORPORATED
Other - Org Name:EYES ON LA GRANGE, DIABETIC EYE CENTERS OF AMERICA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:STAFF
Authorized Official - Prefix:MISS
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:P
Authorized Official - Last Name:LAFINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-499-0123
Mailing Address - Street 1:22 W HARRIS AVE
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-2332
Mailing Address - Country:US
Mailing Address - Phone:708-639-4270
Mailing Address - Fax:708-639-4271
Practice Address - Street 1:22 W HARRIS AVE
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:IL
Practice Address - Zip Code:60525-2332
Practice Address - Country:US
Practice Address - Phone:708-639-4270
Practice Address - Fax:708-639-4271
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-28
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046010097152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty