Provider Demographics
NPI:1487727046
Name:THE VISION SALON, LTD.
Entity type:Organization
Organization Name:THE VISION SALON, LTD.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANSEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:708-385-0013
Mailing Address - Street 1:12812 WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:BLUE ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60406-2118
Mailing Address - Country:US
Mailing Address - Phone:708-385-0013
Mailing Address - Fax:708-385-1175
Practice Address - Street 1:12812 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:BLUE ISLAND
Practice Address - State:IL
Practice Address - Zip Code:60406-2118
Practice Address - Country:US
Practice Address - Phone:708-385-0013
Practice Address - Fax:708-385-1175
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2010-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1636075OtherBCBS OF IL ID
IL1636075OtherBCBS OF IL ID
IL1636075OtherBCBS OF IL ID
=========OtherTAX ID
410011831Medicare ID - Type UnspecifiedRAILROAD MEDICARE ID