Provider Demographics
NPI:1144711243
Name:BRIDGEPORT EYE CARE, LLC
Entity type:Organization
Organization Name:BRIDGEPORT EYE CARE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AVALON
Authorized Official - Middle Name:
Authorized Official - Last Name:HINDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:773-890-1100
Mailing Address - Street 1:3125 S ASHLAND AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-6231
Mailing Address - Country:US
Mailing Address - Phone:773-890-1100
Mailing Address - Fax:
Practice Address - Street 1:3125 S ASHLAND AVE STE 204
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-6231
Practice Address - Country:US
Practice Address - Phone:773-890-1100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-24
Last Update Date:2018-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046010771152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046010771Medicaid
IL1912314477OtherOPTOMETRY NPI