Healthcare Provider Details

I. General information

NPI: 1740464296
Provider Name (Legal Business Name): BUENA VISTA OPTICAL, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2007
Last Update Date: 09/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6455 S KEDZIE AVE
CHICAGO IL
60629-2829
US

IV. Provider business mailing address

6455 S KEDZIE AVE
CHICAGO IL
60629-2829
US

V. Phone/Fax

Practice location:
  • Phone: 773-863-9234
  • Fax: 773-863-9274
Mailing address:
  • Phone: 773-863-9234
  • Fax: 773-863-9274

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number046-009243
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number046-009243
License Number StateIL

VIII. Authorized Official

Name: DR. TODD SIMS
Title or Position: PRESIDENT
Credential: O.D.
Phone: 773-863-9234