Provider Demographics
NPI:1194917971
Name:SUSAN M PENNER
Entity type:Organization
Organization Name:SUSAN M PENNER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:PENNER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:815-234-2020
Mailing Address - Street 1:134 E BLACKHAWK DR
Mailing Address - Street 2:
Mailing Address - City:BYRON
Mailing Address - State:IL
Mailing Address - Zip Code:61010-8610
Mailing Address - Country:US
Mailing Address - Phone:815-234-2020
Mailing Address - Fax:815-234-7070
Practice Address - Street 1:134 E BLACKHAWK DR
Practice Address - Street 2:
Practice Address - City:BYRON
Practice Address - State:IL
Practice Address - Zip Code:61010-8610
Practice Address - Country:US
Practice Address - Phone:815-234-2020
Practice Address - Fax:815-234-7070
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUSAN M PENNER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-15
Last Update Date:2007-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty