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NPI Code Detail

MEDICARE: BLW OPTICAL, INC

MEDICARE: BLW OPTICAL, 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
1152W00000XOptometrist046008205IL

General Provider Information

NPI Number : 1629175849
Entity Type Code : Organization
Provider Name (Legal Business Name) : BLW OPTICAL, INC
Provider Business Mailing Address
First Line : 9617 S WESTERN AVE
Second Line :
City : CHICAGO
State : IL
Zip : 60643-1722
Country : US
Telephone Number : 708-425-4350
Fax Number : 708-425-4359
Provider Business Practice Location Address
First Line : 9617 S WESTERN AVE
Second Line :
City : CHICAGO
State : IL
Zip : 60643-1722
Country : US
Telephone Number : 708-425-4350
Fax Number : 708-425-4359
Authorized Official
Title or Position : OWNER
Name : DR. LONNIE WILLIAMS
Credential : OD
Telephone Number : 708-425-4350
Provider Enumeration Date : 09/20/2006
Last Update Date : 12/17/2013

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