MEDICARE: BELLA VISTA OPTICAL PLLC

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	261QH0100X	Health Service Clinic/Center
2	152W00000X	Optometrist

General Provider Information

NPI Number	:	1154607943
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BELLA VISTA OPTICAL PLLC

Provider Business Mailing Address
First Line	:	7734 N 59TH AVE
Second Line	:	SUITE 102
City	:	GLENDALE
State	:	AZ
Zip	:	85301-7816
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7122 N 59TH AVE FL 1
Second Line	:
City	:	GLENDALE
State	:	AZ
Zip	:	85301-2436
Country	:	US
Telephone Number	:	623-931-1043
Fax Number	:

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. SELVIN GNANAKKAN
Credential	:	O.D.
Telephone Number	:	602-770-9300

Provider Enumeration Date	:	10/25/2011
Last Update Date	:	04/14/2021

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