Healthcare Provider Details

I. General information

NPI: 1669150728
Provider Name (Legal Business Name): MEDICAL ARTS CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2023
Last Update Date: 02/06/2025
Certification Date: 02/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 N LA SALLE DR STE 625
CHICAGO IL
60654-3708
US

IV. Provider business mailing address

620 N LA SALLE DR STE 625
CHICAGO IL
60654-3708
US

V. Phone/Fax

Practice location:
  • Phone: 832-725-5664
  • Fax:
Mailing address:
  • Phone: 832-725-5664
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code156FX1700X
TaxonomyOcularist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code229N00000X
TaxonomyAnaplastologist
License Number
License Number State

VIII. Authorized Official

Name: EDUARDO ARIAS AMEZQUITA
Title or Position: ANAPLASTOLOGIST /OCULARIST
Credential: CCA
Phone: 832-725-5664