Healthcare Provider Details

I. General information

NPI: 1831120088
Provider Name (Legal Business Name): WILMA, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 12/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

904 W NORTH AVE
MELROSE PARK IL
60160-1520
US

IV. Provider business mailing address

904 W NORTH AVE
MELROSE PARK IL
60160-1520
US

V. Phone/Fax

Practice location:
  • Phone: 708-343-9009
  • Fax: 708-343-9012
Mailing address:
  • Phone: 708-343-9009
  • Fax: 708-343-9012

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number060-005866
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number060005866
License Number StateIL

VIII. Authorized Official

Name: DR. SPENCER PAUL VIDULICH
Title or Position: OWNER/DOCTOR
Credential: O.D.
Phone: 773-327-3000