Healthcare Provider Details

I. General information

NPI: 1356588511
Provider Name (Legal Business Name): OPTICAL EXPRESSIONS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2009
Last Update Date: 10/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 DANADA SQ W
WHEATON IL
60189-2041
US

IV. Provider business mailing address

160 DANADA SQ W
WHEATON IL
60189-2041
US

V. Phone/Fax

Practice location:
  • Phone: 630-752-0595
  • Fax: 630-752-0145
Mailing address:
  • Phone: 630-752-0595
  • Fax: 630-752-0145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046007064
License Number StateIL

VIII. Authorized Official

Name: RICHARD MITAL
Title or Position: PRESIDENT
Credential: A.B.O.C.
Phone: 630-752-0595