Healthcare Provider Details

I. General information

NPI: 1154607943
Provider Name (Legal Business Name): BELLA VISTA OPTICAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2011
Last Update Date: 04/14/2021
Certification Date: 04/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7122 N 59TH AVE FL 1
GLENDALE AZ
85301-2436
US

IV. Provider business mailing address

7734 N 59TH AVE SUITE 102
GLENDALE AZ
85301-7816
US

V. Phone/Fax

Practice location:
  • Phone: 623-931-1043
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. SELVIN GNANAKKAN
Title or Position: MEDICAL DIRECTOR
Credential: O.D.
Phone: 602-770-9300