Basic Information
Provider Information | |||||||||
NPI: | 1285806281 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CONSOLIDATED VISION GROUP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | AMERICA'S BEST CONTACTS & EYEGLASSES | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 296 GRAYSON HIGHWAY | ||||||||
Address2: |   | ||||||||
City: | LAWRENCEVILLE | ||||||||
State: | GA | ||||||||
PostalCode: | 30046 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7708223600 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 6375 ULALI DRIVE | ||||||||
Address2: |   | ||||||||
City: | KEIZER | ||||||||
State: | OR | ||||||||
PostalCode: | 97303 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5034285096 | ||||||||
FaxNumber: | 5034637253 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/31/2008 | ||||||||
LastUpdateDate: | 01/13/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MONAHAN | ||||||||
AuthorizedOfficialFirstName: | SHAWN | ||||||||
AuthorizedOfficialMiddleName: | T. | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR, MANAGED CARE | ||||||||
AuthorizedOfficialTelephone: | 6788923283 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | NATIONAL VISION INC | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 156FX1800X |   |   | N | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Technician/Technologist | Optician | 332H00000X |   |   | Y |   | Suppliers | Eyewear Supplier (Equipment, not the service) |   |
No ID Information.