Provider Demographics
NPI:1881965523
Name:JUCKETT EYE CARE CENTER LTD
Entity type:Organization
Organization Name:JUCKETT EYE CARE CENTER LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:SHEDD
Authorized Official - Last Name:JUCKETT
Authorized Official - Suffix:JR
Authorized Official - Credentials:OD
Authorized Official - Phone:847-384-2020
Mailing Address - Street 1:133 S NORTHWEST HWY
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-4228
Mailing Address - Country:US
Mailing Address - Phone:847-384-2020
Mailing Address - Fax:847-823-2020
Practice Address - Street 1:133 S NORTHWEST HWY
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-4228
Practice Address - Country:US
Practice Address - Phone:847-384-2020
Practice Address - Fax:847-823-2020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-25
Last Update Date:2013-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046007733152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL6822Medicare PIN