Provider Demographics
NPI:1245307636
Name:BRENART EYE CLINIC, LLC
Entity type:Organization
Organization Name:BRENART EYE CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:E
Authorized Official - Last Name:MELICK
Authorized Official - Suffix:
Authorized Official - Credentials:COA, OCS
Authorized Official - Phone:630-553-6166
Mailing Address - Street 1:120 E COUNTRYSIDE PKWY
Mailing Address - Street 2:
Mailing Address - City:YORKVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60560-1877
Mailing Address - Country:US
Mailing Address - Phone:630-553-6166
Mailing Address - Fax:630-553-6178
Practice Address - Street 1:120 E COUNTRYSIDE PKWY
Practice Address - Street 2:
Practice Address - City:YORKVILLE
Practice Address - State:IL
Practice Address - Zip Code:60560-1877
Practice Address - Country:US
Practice Address - Phone:630-553-6166
Practice Address - Fax:630-553-6178
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046006926152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046008133Medicaid
IL046008147Medicaid
IL046009086Medicaid
IL046010275OtherLICENSE
IL046006926Medicaid
IL046009279Medicaid
IL046009279Medicaid
ILT88657Medicare UPIN
ILU80934Medicare UPIN
IL046009086Medicaid
IL046006926Medicaid
IL3872660001Medicare NSC
IL046010275OtherLICENSE
ILL80109Medicare PIN
ILT37871Medicare UPIN
IL046008133Medicaid
ILL89686Medicare PIN
ILL98630Medicare PIN