MEDICARE: AMERICAN CRYSTAL OPTICAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center	261Q00000X	IL

General Provider Information

NPI Number	:	1447400676
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AMERICAN CRYSTAL OPTICAL

Provider Business Mailing Address
First Line	:	3752 W FULLERTON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-2331
Country	:	US
Telephone Number	:	773-252-5025
Fax Number	:	773-252-6425

Provider Business Practice Location Address
First Line	:	3752 W FULLERTON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-2331
Country	:	US
Telephone Number	:	773-252-5025
Fax Number	:	773-252-6425

Authorized Official
Title or Position	:	MANAGER
Name	:	MRS. CARMEN ZUNIGA
Credential	:	OWNER
Telephone Number	:	773-252-5025

Provider Enumeration Date	:	09/24/2008
Last Update Date	:	09/24/2008

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