Provider Demographics
NPI:1770712531
Name:ADVANCED EYE CARE SC
Entity type:Organization
Organization Name:ADVANCED EYE CARE SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:A
Authorized Official - Last Name:KISLA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:815-485-2727
Mailing Address - Street 1:1870 SILVER CROSS BOULEVARD
Mailing Address - Street 2:SUITE110
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451
Mailing Address - Country:US
Mailing Address - Phone:815-485-2727
Mailing Address - Fax:815-485-3034
Practice Address - Street 1:1870 SILVER CROSS BOULEVARD
Practice Address - Street 2:SUITE110
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451
Practice Address - Country:US
Practice Address - Phone:815-485-2727
Practice Address - Fax:815-485-3034
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-14
Last Update Date:2010-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042618144332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6417760001Medicare NSC