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General NPI Number Information
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NPI Number | 1912456195
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Entity Type | Organization
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Legal Business Name | RICARDO JOSE NIEVES
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Dates
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Enumeration Date | 09/28/2016
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Last Update Date | 10/11/2016
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Provider Practice Location Address
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Address Line | 1044 N FRANCISCO AVE
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City | CHICAGO
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State | IL
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Zip | 60622-2743
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Country | US
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Telephone | 773-292-8254
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Fax |
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Provider Business Mailing Address
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Address Line | 4230 W 26TH ST
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City | CHICAGO
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State | IL
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Zip | 60623-4316
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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 | OFFICE MANAGER
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Name | MARI GOUDY
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Credential |
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Telephone | 773-292-8254
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number | 036089692
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License Number State | IL
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