Provider Demographics
NPI:1801265657
Name:EVANSTON EYE WELLNESS INC.
Entity type:Organization
Organization Name:EVANSTON EYE WELLNESS INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DEANA
Authorized Official - Middle Name:
Authorized Official - Last Name:LABROSSE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:847-350-7952
Mailing Address - Street 1:716 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-1816
Mailing Address - Country:US
Mailing Address - Phone:847-350-7952
Mailing Address - Fax:847-929-9764
Practice Address - Street 1:716 MAIN ST
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202-1816
Practice Address - Country:US
Practice Address - Phone:847-350-7952
Practice Address - Fax:847-929-9764
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-23
Last Update Date:2016-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046009750152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046009750Medicaid