Provider Demographics
NPI:1750407326
Name:CARILLON VISION CARE
Entity type:Organization
Organization Name:CARILLON VISION CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:
Authorized Official - Last Name:AGREST
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:847-657-8787
Mailing Address - Street 1:1900 WAUKEGAN ROAD
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60025-1714
Mailing Address - Country:US
Mailing Address - Phone:847-657-8787
Mailing Address - Fax:847-657-8730
Practice Address - Street 1:1900 WAUKEGAN RD
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60025-1714
Practice Address - Country:US
Practice Address - Phone:847-657-8787
Practice Address - Fax:847-657-8730
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2009-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL464927152W00000X
IL467979152W00000X
IL0718540001332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear Supplier
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK26156Medicare UPIN
ILK26157Medicare UPIN
0718540001Medicare NSC