Provider Demographics
NPI:1447407085
Name:ELK GROVE OPTICAL, P.C.
Entity type:Organization
Organization Name:ELK GROVE OPTICAL, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST (O.D.)
Authorized Official - Prefix:
Authorized Official - First Name:SUNG
Authorized Official - Middle Name:Y
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-584-9900
Mailing Address - Street 1:611 MEACHAM RD
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE VILLAGE
Mailing Address - State:IL
Mailing Address - Zip Code:60007-3020
Mailing Address - Country:US
Mailing Address - Phone:847-584-9900
Mailing Address - Fax:847-584-9905
Practice Address - Street 1:611 MEACHAM RD
Practice Address - Street 2:
Practice Address - City:ELK GROVE VILLAGE
Practice Address - State:IL
Practice Address - Zip Code:60007-3020
Practice Address - Country:US
Practice Address - Phone:847-584-9900
Practice Address - Fax:847-584-9905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-26
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046009854152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty