Basic Information
| Provider Information | |||||||||
| NPI: | 1295188050 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VISTA OPTICAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2435 COMMERCE AVE | ||||||||
| Address2: | BLDG 2200 | ||||||||
| City: | DULUTH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300964980 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708223600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 102 W OCTAGON ST | ||||||||
| Address2: | BLDG 77B | ||||||||
| City: | CANNON AFB | ||||||||
| State: | NM | ||||||||
| PostalCode: | 881035207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5759041001 | ||||||||
| FaxNumber: | 5757849722 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2016 | ||||||||
| LastUpdateDate: | 09/17/2021 | ||||||||
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| AuthorizedOfficialLastName: | VAUGHN | ||||||||
| AuthorizedOfficialFirstName: | LEAHANN | ||||||||
| AuthorizedOfficialMiddleName: | RENE | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4704482782 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NATIONAL VISION, INC. | ||||||||
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| NPICertificationDate: | 09/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 156FX1800X | N | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Technician/Technologist | Optician | 152W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.