Healthcare Provider Details

I. General information

NPI: 1750330411
Provider Name (Legal Business Name): VISION SALON EYE CARE ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13046 WESTERN AVE
BLUE ISLAND IL
60406-2419
US

IV. Provider business mailing address

13046 WESTERN AVE
BLUE ISLAND IL
60406-2419
US

V. Phone/Fax

Practice location:
  • Phone: 708-385-0013
  • Fax: 708-385-1175
Mailing address:
  • Phone: 708-385-0013
  • Fax: 708-385-1175

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number
License Number StateIL

VIII. Authorized Official

Name: DR. ANSEL T JOHNSON
Title or Position: DOCTOR OF OPTOMETRY
Credential:
Phone: 708-385-0013