Provider Demographics
NPI:1568443257
Name:VIDULICH, BLASE & VALENTINO, P.C.
Entity Type:Organization
Organization Name:VIDULICH, BLASE & VALENTINO, P.C.
Other - Org Name:PEARLE EXPRESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SPENCER
Authorized Official - Middle Name:P
Authorized Official - Last Name:VIDULICH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:773-327-3000
Mailing Address - Street 1:1730 W FULLERTON AVE
Mailing Address - Street 2:PEARLE EXPRESS
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-1900
Mailing Address - Country:US
Mailing Address - Phone:773-327-3000
Mailing Address - Fax:773-327-3015
Practice Address - Street 1:1730 W FULLERTON AVE
Practice Address - Street 2:PEARLE EXPRESS
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-1900
Practice Address - Country:US
Practice Address - Phone:773-327-3000
Practice Address - Fax:773-327-3015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-09
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL958640OtherMEDICARE GROUP NUMBER