Provider Demographics
NPI:1578655593
Name:INDUSTRIAL OPTICAL SERVICE INC
Entity type:Organization
Organization Name:INDUSTRIAL OPTICAL SERVICE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:CARRIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROITSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:312-673-7192
Mailing Address - Street 1:4418 W DIVERSEY AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60639-1924
Mailing Address - Country:US
Mailing Address - Phone:773-736-6800
Mailing Address - Fax:
Practice Address - Street 1:4418 W DIVERSEY AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60639-1924
Practice Address - Country:US
Practice Address - Phone:773-736-6800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046009870Medicaid
IL046009721Medicaid
IL7235044OtherAETNA
IL046008138Medicaid
IL046008974Medicaid
IL046009268Medicaid
IL1636706OtherBCBS
IL046008138Medicaid
IL210209Medicare PIN