Basic Information
Provider Information | |||||||||
NPI: | 1235877465 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NATIONAL VISION INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2435 COMMERCE AVE BLDG 2200 | ||||||||
Address2: |   | ||||||||
City: | DULUTH | ||||||||
State: | GA | ||||||||
PostalCode: | 300964980 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7708223600 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 426 LINCOLN AVE | ||||||||
Address2: |   | ||||||||
City: | EAST STROUDSBURG | ||||||||
State: | PA | ||||||||
PostalCode: | 183012893 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5705346113 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/26/2022 | ||||||||
LastUpdateDate: | 05/26/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GARRISON | ||||||||
AuthorizedOfficialFirstName: | JULIE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGED CARE STORE ENROLLMENT | ||||||||
AuthorizedOfficialTelephone: | 7702127579 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/26/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |   |
No ID Information.