Provider Demographics
NPI:1639252273
Name:NORTHERN ILLINOIS OPTICAL CO., INC.
Entity Type:Organization
Organization Name:NORTHERN ILLINOIS OPTICAL CO., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHERI
Authorized Official - Middle Name:M
Authorized Official - Last Name:DE ROSSO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-963-3454
Mailing Address - Street 1:121 N MADISON ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-3949
Mailing Address - Country:US
Mailing Address - Phone:815-963-3454
Mailing Address - Fax:815-963-4384
Practice Address - Street 1:121 N MADISON ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-3949
Practice Address - Country:US
Practice Address - Phone:815-963-3454
Practice Address - Fax:815-963-4384
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL10115103OtherBCBS
IL10115103OtherBCBS