Provider Demographics
NPI:1760467070
Name:WHEATON EYE CLINIC LTD
Entity Type:Organization
Organization Name:WHEATON EYE CLINIC LTD
Other - Org Name:HINSDALE OPTICAL DEPARTMENT
Other - Org Type:Other Name
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-588-3630
Mailing Address - Street 1:2015 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187-3152
Mailing Address - Country:US
Mailing Address - Phone:630-668-8250
Mailing Address - Fax:630-668-8916
Practice Address - Street 1:908 N ELM ST
Practice Address - Street 2:SUITE 101
Practice Address - City:HINSDALE
Practice Address - State:IL
Practice Address - Zip Code:60521-3635
Practice Address - Country:US
Practice Address - Phone:630-668-8250
Practice Address - Fax:630-668-8916
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WHEATON EYE CLINIC, LTD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-12-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207W00000X
332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear Supplier
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0534150003Medicare NSC