=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427148725
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RASA TAMULAVICHUS O.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/15/2006
-----------------------------------------------------
Last Update Date | 01/16/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2500 W 95TH ST WALMART VISION CENTER
-----------------------------------------------------
City | EVERGREEN PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60805-2807
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-229-0946
-----------------------------------------------------
Fax | 708-229-0973
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 16974
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60616-0980
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-550-7034
-----------------------------------------------------
Fax | 708-229-0973
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 046-009691
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------