Provider Demographics
NPI:1184800625
Name:NORTHWEST EYECARE PC
Entity type:Organization
Organization Name:NORTHWEST EYECARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:NIKOLAS
Authorized Official - Middle Name:S
Authorized Official - Last Name:DIEMER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:815-235-6177
Mailing Address - Street 1:1000 KIWANIS DR
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:61032-6921
Mailing Address - Country:US
Mailing Address - Phone:815-235-6177
Mailing Address - Fax:815-235-6180
Practice Address - Street 1:1000 KIWANIS DR
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-6921
Practice Address - Country:US
Practice Address - Phone:815-235-6177
Practice Address - Fax:815-235-6180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-15
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCC3859Medicare PIN
IL0724420001Medicare NSC
ILCC3861Medicare PIN
IL210870Medicare PIN
ILCN7121Medicare PIN