Provider Demographics
NPI:1831120088
Name:WILMA, LTD
Entity type:Organization
Organization Name:WILMA, LTD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SPENCER
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:VIDULICH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:773-327-3000
Mailing Address - Street 1:904 W NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:MELROSE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60160-1520
Mailing Address - Country:US
Mailing Address - Phone:708-343-9009
Mailing Address - Fax:708-343-9012
Practice Address - Street 1:904 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:MELROSE PARK
Practice Address - State:IL
Practice Address - Zip Code:60160-1520
Practice Address - Country:US
Practice Address - Phone:708-343-9009
Practice Address - Fax:708-343-9012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2008-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL060005866332H00000X
IL060-005866152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL323130Medicare ID - Type Unspecified
IL0494080001Medicare NSC