Provider Demographics
NPI:1558546713
Name:HALSTED EYE BOUTIQUE, INC.
Entity Type:Organization
Organization Name:HALSTED EYE BOUTIQUE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:SLUSKY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:847-477-5612
Mailing Address - Street 1:697 LYSTER RD
Mailing Address - Street 2:
Mailing Address - City:HIGHWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60040-2007
Mailing Address - Country:US
Mailing Address - Phone:847-477-5612
Mailing Address - Fax:
Practice Address - Street 1:2852 N HALSTED ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-6531
Practice Address - Country:US
Practice Address - Phone:773-549-1111
Practice Address - Fax:773-546-1116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-07
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-008926152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty