Provider Demographics
NPI:1801987367
Name:ARSENEAU OPTICAL OF KANKAKEE INC
Entity type:Organization
Organization Name:ARSENEAU OPTICAL OF KANKAKEE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES OPTICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:TROST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-933-5798
Mailing Address - Street 1:135 W COURT ST
Mailing Address - Street 2:
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901
Mailing Address - Country:US
Mailing Address - Phone:815-933-5798
Mailing Address - Fax:815-929-5760
Practice Address - Street 1:135 W COURT ST
Practice Address - Street 2:
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901
Practice Address - Country:US
Practice Address - Phone:815-933-5798
Practice Address - Fax:815-929-5760
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2013-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
No156F00000XEye and Vision Services ProvidersTechnician/TechnologistGroup - Multi-Specialty
No156FC0800XEye and Vision Services ProvidersTechnician/TechnologistContact LensGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL1521OtherMEDICARE PTAN
IL=========001Medicaid