Provider Demographics
NPI:1538489737
Name:NORTH SHORE OPTICAL INC.
Entity Type:Organization
Organization Name:NORTH SHORE OPTICAL INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:D
Authorized Official - Last Name:DEWAARD
Authorized Official - Suffix:
Authorized Official - Credentials:O D
Authorized Official - Phone:773-764-3873
Mailing Address - Street 1:7559 N PAULINA ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60626-1692
Mailing Address - Country:US
Mailing Address - Phone:773-764-3873
Mailing Address - Fax:773-465-4893
Practice Address - Street 1:7559 N PAULINA ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60626-1692
Practice Address - Country:US
Practice Address - Phone:773-764-3873
Practice Address - Fax:773-465-4893
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-10
Last Update Date:2010-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046007174152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty