MEDICARE: KIMBERLY MARIA MATHIS-HARRIS

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	332H00000X	Eyewear Supplier
2	156FX1800X	Optician

General Provider Information

NPI Number	:	1619566627
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMBERLY MARIA MATHIS-HARRIS

Provider Business Mailing Address
First Line	:	10908 S HALSTED ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60628-3128
Country	:	US
Telephone Number	:	773-339-6556
Fax Number	:	773-701-6055

Provider Business Practice Location Address
First Line	:	10908 S HALSTED ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60628-3128
Country	:	US
Telephone Number	:	773-339-6556
Fax Number	:	773-701-6055

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/14/2021
Last Update Date	:	05/28/2025

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