Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | IL |
NPI | 1003896671 |
---|---|
Provider Name | Laura Cretors |
First Address | Gurnee, IL 60031-2597 |
Second Address | Antioch, IL 60002-1226 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/01/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
U78972 | (02) | IL |