Provider Demographics
NPI:1154607943
Name:BELLA VISTA OPTICAL PLLC
Entity type:Organization
Organization Name:BELLA VISTA OPTICAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SELVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:GNANAKKAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:602-770-9300
Mailing Address - Street 1:7734 N 59TH AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85301-7816
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7122 N 59TH AVE FL 1
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85301-2436
Practice Address - Country:US
Practice Address - Phone:623-931-1043
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-25
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth ServiceGroup - Single Specialty