MEDICARE: PLANO CHILD DEVELOPMENT CENTER

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	152WV0400X	Vision Therapy Optometrist

General Provider Information

NPI Number	:	1962639781
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PLANO CHILD DEVELOPMENT CENTER

Provider Business Mailing Address
First Line	:	5401 S WENTWORTH AVE STE 14A
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60609-6300
Country	:	US
Telephone Number	:	773-924-5297
Fax Number	:	773-373-3548

Provider Business Practice Location Address
First Line	:	5401 S WENTWORTH AVE STE 14A
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60609-6300
Country	:	US
Telephone Number	:	773-924-5297
Fax Number	:	773-373-3548

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ROBERT L. JOHNSON SR.
Credential	:	O.D.
Telephone Number	:	773-924-5297

Provider Enumeration Date	:	06/18/2009
Last Update Date	:	06/18/2009

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Directions to “PLANO CHILD DEVELOPMENT CENTER ” Practice Location

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