Provider Demographics
NPI:1154552016
Name:CRYSTAL CLEAR EYE CARE CLINIC
Entity type:Organization
Organization Name:CRYSTAL CLEAR EYE CARE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANGER
Authorized Official - Prefix:
Authorized Official - First Name:SHERRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BAKOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-524-1700
Mailing Address - Street 1:1760 WISE
Mailing Address - Street 2:
Mailing Address - City:SCHAUMBERG
Mailing Address - State:IL
Mailing Address - Zip Code:60193
Mailing Address - Country:US
Mailing Address - Phone:847-524-1700
Mailing Address - Fax:847-524-1702
Practice Address - Street 1:1760 WISE
Practice Address - Street 2:
Practice Address - City:SCHAUMBERG
Practice Address - State:IL
Practice Address - Zip Code:60193
Practice Address - Country:US
Practice Address - Phone:847-524-1700
Practice Address - Fax:847-524-1702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-27
Last Update Date:2010-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046007080305R00000X
IL047935456305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1730125451OtherNPI
IL1841370061OtherNPI
ILIL2691Medicare PIN
IL1841370061OtherNPI