=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255172334
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | R A VISION CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/04/2024
-----------------------------------------------------
Last Update Date | 06/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 118 MAIN ST
-----------------------------------------------------
City | PARK RIDGE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60068-4030
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-696-6444
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 118 MAIN ST
-----------------------------------------------------
City | PARK RIDGE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60068-4030
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OD
-----------------------------------------------------
Name | R P
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 847-696-6444
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------