MEDICARE: PUPIL VISION CENTER

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	302R00000X	Health Maintenance Organization
2	156FX1202X	Optometric Technician

General Provider Information

NPI Number	:	1982005260
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PUPIL VISION CENTER

Provider Business Mailing Address
First Line	:	5233 N LINCOLN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-2405
Country	:	US
Telephone Number	:	312-350-8269
Fax Number	:

Provider Business Practice Location Address
First Line	:	5233 N LINCOLN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-2405
Country	:	US
Telephone Number	:	312-350-8269
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	RENEE RUSSO
Credential	:
Telephone Number	:	312-350-8269

Provider Enumeration Date	:	09/05/2014
Last Update Date	:	09/05/2014

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Directions to “PUPIL VISION CENTER ” Practice Location

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