Basic Information
| Provider Information | |||||||||
| NPI: | 1124011788 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BELLEN | ||||||||
| FirstName: | BREEZE | ||||||||
| MiddleName: | EVELYN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FEILER | ||||||||
| OtherFirstName: | BREEZE | ||||||||
| OtherMiddleName: | EVELYN | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | O.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 519 W MELROSE ST | ||||||||
| Address2: | APT 412 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606573764 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7735057039 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4740 N LINCOLN AVE | ||||||||
| Address2: | FL 1 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606252247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732752900 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2005 | ||||||||
| LastUpdateDate: | 09/04/2009 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 046009782 | IL | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.