Provider Demographics
NPI:1568900140
Name:BIG CITY OPTICAL LLC
Entity Type:Organization
Organization Name:BIG CITY OPTICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:VYTAUTAS
Authorized Official - Middle Name:
Authorized Official - Last Name:TAMULIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-483-9504
Mailing Address - Street 1:PO BOX 16974
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-0980
Mailing Address - Country:US
Mailing Address - Phone:815-483-9504
Mailing Address - Fax:
Practice Address - Street 1:1350 W 18TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-3148
Practice Address - Country:US
Practice Address - Phone:815-483-9504
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-03
Last Update Date:2017-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046009691152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046009691Medicaid
IL046009691Medicaid