Provider Demographics
NPI:1750747721
Name:EYES ON FULTON LLC
Entity type:Organization
Organization Name:EYES ON FULTON LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KAORI
Authorized Official - Middle Name:
Authorized Official - Last Name:ASANO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:310-903-0908
Mailing Address - Street 1:1011 W FULTON MARKET
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-1222
Mailing Address - Country:US
Mailing Address - Phone:312-226-2020
Mailing Address - Fax:312-226-2021
Practice Address - Street 1:1011 W FULTON MARKET
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607-1222
Practice Address - Country:US
Practice Address - Phone:312-226-2020
Practice Address - Fax:312-226-2021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-06
Last Update Date:2016-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046009874152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046009874Medicaid
K29383Medicare PIN
09777Medicare UPIN