Provider Demographics
NPI:1629229992
Name:ADVANCE VISION CARE PC
Entity Type:Organization
Organization Name:ADVANCE VISION CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMOTRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:M
Authorized Official - Last Name:O'BRIEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:708-636-5115
Mailing Address - Street 1:5706 111TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60415-2407
Mailing Address - Country:US
Mailing Address - Phone:708-636-5115
Mailing Address - Fax:708-636-5162
Practice Address - Street 1:5706 111TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60415-2407
Practice Address - Country:US
Practice Address - Phone:708-636-5115
Practice Address - Fax:708-636-5162
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-06
Last Update Date:2008-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0334230001Medicare NSC