Provider Demographics
NPI:1609908920
Name:NORTHWEST OPTOMETRIC ASSOCIATES, LTD
Entity Type:Organization
Organization Name:NORTHWEST OPTOMETRIC ASSOCIATES, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DENICE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:RICE-KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:708-867-7838
Mailing Address - Street 1:4970 N HARLEM AVE
Mailing Address - Street 2:
Mailing Address - City:HARWOOD HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60706-3552
Mailing Address - Country:US
Mailing Address - Phone:708-867-7838
Mailing Address - Fax:708-867-5869
Practice Address - Street 1:4970 N HARLEM AVE
Practice Address - Street 2:
Practice Address - City:HARWOOD HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60706-3552
Practice Address - Country:US
Practice Address - Phone:708-867-7838
Practice Address - Fax:708-867-5869
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2008-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046008854152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU60758Medicare UPIN
IL521020Medicare PIN
ILL66988Medicare ID - Type Unspecified