MEDICARE: OPTICAL 88 2020 INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	156FX1800X	Optician

General Provider Information

NPI Number	:	1013533058
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPTICAL 88 2020 INC

Provider Business Mailing Address
First Line	:	724 W 31ST ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60616-3007
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	724 W 31ST ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60616-3007
Country	:	US
Telephone Number	:	312-842-1888
Fax Number	:

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	YAYUAN LI
Credential	:
Telephone Number	:	312-842-1888

Provider Enumeration Date	:	06/24/2020
Last Update Date	:	06/24/2020

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