Provider Demographics
NPI:1578719308
Name:ASSOCIATED OPTICAL
Entity Type:Organization
Organization Name:ASSOCIATED OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CARRIE
Authorized Official - Middle Name:SPENCER
Authorized Official - Last Name:SYPHERD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:630-820-1303
Mailing Address - Street 1:4050 HEALTHWAY DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60504-8183
Mailing Address - Country:US
Mailing Address - Phone:630-820-1303
Mailing Address - Fax:
Practice Address - Street 1:4050 HEALTHWAY DR
Practice Address - Street 2:SUITE 100
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60504-8183
Practice Address - Country:US
Practice Address - Phone:630-820-1303
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-12
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046009482152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1992756290Medicaid
ILK18430Medicare UPIN