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General NPI Number Information
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NPI Number | 1942220256
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Entity Type | Organization
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Legal Business Name | BLAIR TANAKA, INC.
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Dates
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Enumeration Date | 07/20/2006
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Last Update Date | 04/11/2013
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Provider Practice Location Address
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Address Line | 402 W BOUGHTON RD SUITE B
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City | BOLINGBROOK
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State | IL
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Zip | 60440-1872
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Country | US
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Telephone | 630-759-5100
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Fax | 630-759-5101
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Provider Business Mailing Address
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Address Line | 402 W BOUGHTON RD SUITE B
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City | BOLINGBROOK
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State | IL
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Zip | 60440-1872
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Country | US
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Telephone | 630-759-5100
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Fax | 630-759-5101
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Authorized Official
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Title or Position | OPTOMETRIST
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Name | BLAIR TANAKA
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Credential | O.D.
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Telephone | 630-499-8227
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 046-008124
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License Number State | IL
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