Provider Demographics
NPI:1104156009
Name:WOW VISION PC
Entity type:Organization
Organization Name:WOW VISION PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:D
Authorized Official - Last Name:WILMOTH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:630-663-9112
Mailing Address - Street 1:7451 WOODWARD AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WOODRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60517-2665
Mailing Address - Country:US
Mailing Address - Phone:630-663-9112
Mailing Address - Fax:630-663-9228
Practice Address - Street 1:7451 WOODWARD AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:WOODRIDGE
Practice Address - State:IL
Practice Address - Zip Code:60517-2665
Practice Address - Country:US
Practice Address - Phone:630-663-9112
Practice Address - Fax:630-663-9228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-28
Last Update Date:2013-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046009127152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty