Provider Demographics
NPI:1881971133
Name:THIRD STREET EYECARE, LTD
Entity type:Organization
Organization Name:THIRD STREET EYECARE, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:D
Authorized Official - Last Name:BURGGRAF
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:815-751-5269
Mailing Address - Street 1:3317 HUSKING PEG LN
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-4656
Mailing Address - Country:US
Mailing Address - Phone:815-751-5269
Mailing Address - Fax:331-248-0328
Practice Address - Street 1:500 S THIRD ST
Practice Address - Street 2:STE 105
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-2762
Practice Address - Country:US
Practice Address - Phone:815-751-5269
Practice Address - Fax:331-248-0328
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-14
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL00466713152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1447318563OtherINDIVIDUAL NPI
IL046006713Medicaid
IL046006713Medicaid
ILMB0216386OtherDEA