Provider Demographics
NPI:1669636270
Name:MIDWEST EYE CLINIC, INC
Entity Type:Organization
Organization Name:MIDWEST EYE CLINIC, INC
Other - Org Name:MIDWEST EYE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ERNESTO
Authorized Official - Middle Name:
Authorized Official - Last Name:CARRASCO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-581-1515
Mailing Address - Street 1:6254 S PULASKI RD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60629-4610
Mailing Address - Country:US
Mailing Address - Phone:773-581-1515
Mailing Address - Fax:773-581-9663
Practice Address - Street 1:6254 S PULASKI RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629-4610
Practice Address - Country:US
Practice Address - Phone:773-581-1515
Practice Address - Fax:773-581-9663
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-12
Last Update Date:2008-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL346002682152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty