Healthcare Provider Details

I. General information

NPI: 1801167275
Provider Name (Legal Business Name): YOLANDA HURT OPTICIAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2012
Last Update Date: 01/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 S 1ST AVE STE 308
MAYWOOD IL
60153-2419
US

IV. Provider business mailing address

1701 S 1ST AVE STE 308
MAYWOOD IL
60153-2419
US

V. Phone/Fax

Practice location:
  • Phone: 708-865-9005
  • Fax: 708-865-9050
Mailing address:
  • Phone: 708-865-9005
  • Fax: 708-865-9050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: