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General NPI Number Information
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NPI Number | 1154607943
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Entity Type | Organization
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Legal Business Name | BELLA VISTA OPTICAL PLLC
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Dates
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Enumeration Date | 10/25/2011
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Last Update Date | 04/14/2021
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Provider Practice Location Address
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Address Line | 7122 N 59TH AVE FL 1
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City | GLENDALE
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State | AZ
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Zip | 85301-2436
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Country | US
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Telephone | 623-931-1043
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Fax |
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Provider Business Mailing Address
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Address Line | 7734 N 59TH AVE SUITE 102
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City | GLENDALE
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State | AZ
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Zip | 85301-7816
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. SELVIN GNANAKKAN
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Credential | O.D.
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Telephone | 602-770-9300
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number |
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License Number State |
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