Provider Demographics
NPI:1740464296
Name:BUENA VISTA OPTICAL, P.C.
Entity type:Organization
Organization Name:BUENA VISTA OPTICAL, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:773-863-9234
Mailing Address - Street 1:6455 S KEDZIE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60629-2829
Mailing Address - Country:US
Mailing Address - Phone:773-863-9234
Mailing Address - Fax:773-863-9274
Practice Address - Street 1:6455 S KEDZIE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629-2829
Practice Address - Country:US
Practice Address - Phone:773-863-9234
Practice Address - Fax:773-863-9274
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-19
Last Update Date:2013-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-009243261Q00000X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No332H00000XSuppliersEyewear Supplier