Organization Name: | INTERSTATE OPTICAL LBR INC |
NPI Number: | 1114965126 |
Entity Type Code: | Organizational (2) |
Authorized Official Name: | GARY LEE STEPHENS (OPTICIAN) |
Mailing Address: | 9612 Willow Ln Mokena |
State: | IL US |
Postal Code: | 604489318 |
Phone Number: | 7084796232 |
Fax Number: | |
NPI Enumeration Date: | 06/02/2006 |
NPI Last Update Date: | 10/19/2007 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 156FX1800X |
License Number: | |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | |
Taxonomy Type: | Eye and Vision Services Providers |
Taxonomy Classification: | Technician/Technologist |
Taxonomy Specialization: | Optician |
Taxonomy Definition: |