Provider Demographics
NPI:1104995299
Name:OPTICAL PLACE LTD.
Entity type:Organization
Organization Name:OPTICAL PLACE LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:E
Authorized Official - Last Name:HINES
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:708-597-6550
Mailing Address - Street 1:4716 147TH ST
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:IL
Mailing Address - Zip Code:60445-2527
Mailing Address - Country:US
Mailing Address - Phone:708-597-6550
Mailing Address - Fax:708-597-5975
Practice Address - Street 1:4716 147TH ST
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:IL
Practice Address - Zip Code:60445-2527
Practice Address - Country:US
Practice Address - Phone:708-597-6550
Practice Address - Fax:708-597-5975
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2011-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-007825152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL3373Medicare PIN