Provider Demographics
NPI:1710284419
Name:PHC OF BUFFALO GROVE OPTOMETRY
Entity Type:Organization
Organization Name:PHC OF BUFFALO GROVE OPTOMETRY
Other - Org Name:PORTRAIT HEALTH CENTERS OF BUFFALO GROVE OPTOMETRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LEXI
Authorized Official - Middle Name:
Authorized Official - Last Name:SURBER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:847-868-3435
Mailing Address - Street 1:150 W HALF DAY RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:BUFFALO GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60089-6591
Mailing Address - Country:US
Mailing Address - Phone:847-868-3435
Mailing Address - Fax:847-859-5855
Practice Address - Street 1:150 W HALF DAY RD
Practice Address - Street 2:SUITE 105
Practice Address - City:BUFFALO GROVE
Practice Address - State:IL
Practice Address - Zip Code:60089-6591
Practice Address - Country:US
Practice Address - Phone:847-868-3435
Practice Address - Fax:847-859-5855
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-16
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046010327152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty