Provider Demographics
NPI:1851741714
Name:BRAIN-EYE EVOLUTION AT 730 NORTH
Entity Type:Organization
Organization Name:BRAIN-EYE EVOLUTION AT 730 NORTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:JODY
Authorized Official - Middle Name:L
Authorized Official - Last Name:RICKETTS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:847-362-9900
Mailing Address - Street 1:730 N MILWAUKEE AVE
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-1914
Mailing Address - Country:US
Mailing Address - Phone:847-362-9900
Mailing Address - Fax:
Practice Address - Street 1:730 N MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-1914
Practice Address - Country:US
Practice Address - Phone:847-362-9900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-21
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Single Specialty