Healthcare Provider Details

I. General information

NPI: 1982005260
Provider Name (Legal Business Name): PUPIL VISION CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2014
Last Update Date: 09/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5233 N LINCOLN AVE
CHICAGO IL
60625-2405
US

IV. Provider business mailing address

5233 N LINCOLN AVE
CHICAGO IL
60625-2405
US

V. Phone/Fax

Practice location:
  • Phone: 312-350-8269
  • Fax:
Mailing address:
  • Phone: 312-350-8269
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1202X
TaxonomyOptometric Technician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number State

VIII. Authorized Official

Name: RENEE RUSSO
Title or Position: ADMINISTRATOR
Credential:
Phone: 312-350-8269