Provider Demographics
NPI:1023080553
Name:LA VALLEE, KEITH (OD)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:
Last Name:LA VALLEE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2111 W SUPERIOR ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-1315
Mailing Address - Country:US
Mailing Address - Phone:312-226-1020
Mailing Address - Fax:312-226-0802
Practice Address - Street 1:2111 W SUPERIOR ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-1315
Practice Address - Country:US
Practice Address - Phone:312-226-1020
Practice Address - Fax:312-226-0802
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist