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General NPI Number Information
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NPI Number | 1740464296
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Entity Type | Organization
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Legal Business Name | BUENA VISTA OPTICAL, P.C.
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Dates
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Enumeration Date | 12/19/2007
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Last Update Date | 09/11/2013
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Provider Practice Location Address
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Address Line | 6455 S KEDZIE AVE
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City | CHICAGO
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State | IL
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Zip | 60629-2829
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Country | US
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Telephone | 773-863-9234
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Fax | 773-863-9274
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Provider Business Mailing Address
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Address Line | 6455 S KEDZIE AVE
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City | CHICAGO
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State | IL
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Zip | 60629-2829
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Country | US
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Telephone | 773-863-9234
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Fax | 773-863-9274
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. TODD SIMS
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Credential | O.D.
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Telephone | 773-863-9234
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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 | 046-009243
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 046-009243
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License Number State | IL
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