Provider Demographics
NPI:1255505624
Name:BLOOMINGDALE OPTICAL,INC
Entity Type:Organization
Organization Name:BLOOMINGDALE OPTICAL,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DOLORES
Authorized Official - Middle Name:B
Authorized Official - Last Name:GUSTAVESON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-980-4446
Mailing Address - Street 1:152 S BLOOMINGDALE RD STE 102
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60108-1495
Mailing Address - Country:US
Mailing Address - Phone:630-980-4446
Mailing Address - Fax:630-980-2313
Practice Address - Street 1:152 S BLOOMINGDALE RD STE 102
Practice Address - Street 2:
Practice Address - City:BLOOMINGDALE
Practice Address - State:IL
Practice Address - Zip Code:60108-1495
Practice Address - Country:US
Practice Address - Phone:630-980-4446
Practice Address - Fax:630-980-2313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-16
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty