Provider Demographics
NPI:1386121283
Name:AEA OPTICAL VENTURES LLC
Entity type:Organization
Organization Name:AEA OPTICAL VENTURES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:LADOCHI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-897-0800
Mailing Address - Street 1:4814 N CLARK ST STE B
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-7767
Mailing Address - Country:US
Mailing Address - Phone:773-897-0800
Mailing Address - Fax:773-897-0457
Practice Address - Street 1:4814 N CLARK ST STE B
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-7767
Practice Address - Country:US
Practice Address - Phone:773-897-0800
Practice Address - Fax:773-897-0457
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AEA OPTICAL VENTURES LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-07-24
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261Q00000X, 261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service