Provider Demographics
NPI:1760971220
Name:WANDERLUST EYECARE, P.C.
Entity Type:Organization
Organization Name:WANDERLUST EYECARE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FAYE THERESE
Authorized Official - Middle Name:P
Authorized Official - Last Name:GAMBOA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:847-787-1187
Mailing Address - Street 1:1745 ORCHARD LN
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60093-3432
Mailing Address - Country:US
Mailing Address - Phone:847-787-1187
Mailing Address - Fax:847-789-7181
Practice Address - Street 1:1745 ORCHARD LN
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:IL
Practice Address - Zip Code:60093-3432
Practice Address - Country:US
Practice Address - Phone:847-787-1187
Practice Address - Fax:847-789-7181
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-09
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046010799152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1275948044OtherNPI TYPE 1