Provider Demographics
NPI:1144083296
Name:PANICKER OPTOMETRY LLC
Entity type:Organization
Organization Name:PANICKER OPTOMETRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:JAISON
Authorized Official - Middle Name:
Authorized Official - Last Name:PANICKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-479-3411
Mailing Address - Street 1:793 BARCLAY DR
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-6105
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1300 DES PLAINES AVE
Practice Address - Street 2:
Practice Address - City:FOREST PARK
Practice Address - State:IL
Practice Address - Zip Code:60130-2507
Practice Address - Country:US
Practice Address - Phone:708-488-0383
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-01
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty