Organization
LORETTA DE KOSTER,O.D. INC.
Active
Other names
Melrose Eyecare Center
Organization subpart
No
Provider details
NPI number
Authorized official
DR. LORETTA DE KOSTER O.D. (CEO)
(708) 456-4362
Entity
Organization
Contact information
Practice address
2528 N HARLEM AVE, MAIN FLOOR, ELMWOOD PARK, IL 60707-2046
(708) 456-4362
(708) 456-5161
Mailing address
2528 N HARLEM AVE, MAIN FLOOR, ELMWOOD PARK, IL 60707-2046
(708) 456-4362
(708) 456-5161
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
046008683
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
01621057
BCBS
IL
05
—
046008683
—
IL
01
—
IL4407
MEDICARE PTAN
IL
Enumeration date
01/30/2008
Last updated
04/15/2012
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