Provider Demographics
NPI:1104628478
Name:FOREST BLUFF OPTOMETRY LLC
Entity type:Organization
Organization Name:FOREST BLUFF OPTOMETRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:YIN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:815-501-7419
Mailing Address - Street 1:1081 OAK SPRING LN
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-1613
Mailing Address - Country:US
Mailing Address - Phone:815-501-7419
Mailing Address - Fax:
Practice Address - Street 1:207-209 N. WAUKEGAN RD
Practice Address - Street 2:
Practice Address - City:LAKE BLUFF
Practice Address - State:IL
Practice Address - Zip Code:60044
Practice Address - Country:US
Practice Address - Phone:815-501-7419
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-26
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty