MEDICARE: VISION BOUTIQUE, 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	152W00000X	Optometrist		IL

General Provider Information

NPI Number	:	1689732232
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VISION BOUTIQUE, INC.

Provider Business Mailing Address
First Line	:	948 W MADISON ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60607-2741
Country	:	US
Telephone Number	:	312-829-6800
Fax Number	:	312-829-3945

Provider Business Practice Location Address
First Line	:	948 W MADISON ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60607-2741
Country	:	US
Telephone Number	:	312-829-6800
Fax Number	:	312-829-3945

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	MR. CHARLES BAYGOOD
Credential	:
Telephone Number	:	312-829-6800

Provider Enumeration Date	:	12/05/2006
Last Update Date	:	08/22/2020

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Directions to “VISION BOUTIQUE, INC. ” Practice Location

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