Provider Demographics
NPI:1538350228
Name:EYEDENTITY VISION CARE, LLC
Entity type:Organization
Organization Name:EYEDENTITY VISION CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:CARR
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:630-232-4211
Mailing Address - Street 1:309 HAMILTON ST STE A
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-2182
Mailing Address - Country:US
Mailing Address - Phone:630-232-4211
Mailing Address - Fax:630-232-7636
Practice Address - Street 1:309 HAMILTON ST STE A
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-2182
Practice Address - Country:US
Practice Address - Phone:630-232-4211
Practice Address - Fax:630-232-7636
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-07
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-008336152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL04532377OtherBLUE CROSS BLUE SHIELD
IL212722Medicare PIN