Basic Information
Provider Information | |||||||||
NPI: | 1063819001 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | VISIONWORKS, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | VISIONWORKS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 848448 | ||||||||
Address2: |   | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 752848448 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2103403531 | ||||||||
FaxNumber: | 2105246587 | ||||||||
Practice Location | |||||||||
Address1: | 277 MUNDY ST | ||||||||
Address2: | SUITE 101 | ||||||||
City: | WILKES BARRE | ||||||||
State: | PA | ||||||||
PostalCode: | 18702 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5708291437 | ||||||||
FaxNumber: | 5708291920 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/19/2014 | ||||||||
LastUpdateDate: | 06/20/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | REYNOLDS | ||||||||
AuthorizedOfficialFirstName: | DOROTHY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR OF MANAGED | ||||||||
AuthorizedOfficialTelephone: | 2105246515 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332H00000X |   |   | Y |   | Suppliers | Eyewear Supplier (Equipment, not the service) |   |
ID Information
ID | Type | State | Issuer | Description | 1014503890045 | 05 | PA |   | MEDICAID | 4852140487 | 01 | PA | MEDICARE | OTHER |