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General NPI Number Information
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NPI Number | 1730754169
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Entity Type | Organization
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Legal Business Name | KIMBERLY MATHIS-HARRIS
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Dates
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Enumeration Date | 05/27/2021
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Last Update Date | 05/27/2021
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Provider Practice Location Address
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Address Line | 1439 W 103RD ST STE 3
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City | CHICAGO
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State | IL
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Zip | 60643-2900
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Country | US
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Telephone | 773-339-6556
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Fax | 773-701-6055
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Provider Business Mailing Address
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Address Line | 1439 W 103RD ST STE 3
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City | CHICAGO
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State | IL
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Zip | 60643-2900
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Country | US
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Telephone | 773-339-6556
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Fax | 773-701-6055
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Authorized Official
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Title or Position | OWNER
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Name | MRS. KIMBERLY MARIA MATHIS-HARRIS
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Credential | OPTICIAN
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Telephone | 773-339-6556
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number |
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License Number State |
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