Provider Demographics
NPI:1568647634
Name:BLANCO KAYS CORGIAT EYECARE, LLC
Entity Type:Organization
Organization Name:BLANCO KAYS CORGIAT EYECARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:M
Authorized Official - Last Name:PARTRIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-663-8281
Mailing Address - Street 1:1802 N DIVISION ST
Mailing Address - Street 2:SUITE 205
Mailing Address - City:MORRIS
Mailing Address - State:IL
Mailing Address - Zip Code:60450-1182
Mailing Address - Country:US
Mailing Address - Phone:815-942-3042
Mailing Address - Fax:815-942-3062
Practice Address - Street 1:1802 DIVISION ST
Practice Address - Street 2:SUITE 205
Practice Address - City:MORRIS
Practice Address - State:IL
Practice Address - Zip Code:60450-1182
Practice Address - Country:US
Practice Address - Phone:815-942-3042
Practice Address - Fax:815-942-3062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-08
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL466809152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILDS4037Medicare PIN
IL6480590001Medicare NSC
ILIL6520Medicare PIN
ILK22822Medicare PIN
IL212625Medicare PIN