Provider Demographics
NPI:1013484674
Name:ELGIN FAMILY EYE CARE LLC
Entity Type:Organization
Organization Name:ELGIN FAMILY EYE CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:PENNER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:815-289-6512
Mailing Address - Street 1:1648 N SAUK TRL
Mailing Address - Street 2:
Mailing Address - City:OREGON
Mailing Address - State:IL
Mailing Address - Zip Code:61061-8978
Mailing Address - Country:US
Mailing Address - Phone:815-289-6512
Mailing Address - Fax:
Practice Address - Street 1:165 S RANDALL RD
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-5551
Practice Address - Country:US
Practice Address - Phone:847-888-1555
Practice Address - Fax:847-888-2508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-31
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty