Basic Information
Provider Information | |||||||||
NPI: | 1376598128 | ||||||||
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: | 296 GRAYSON HWY | ||||||||
Address2: |   | ||||||||
City: | LAWRENCEVILLE | ||||||||
State: | GA | ||||||||
PostalCode: | 300465737 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7708223600 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1825 W BELL RD | ||||||||
Address2: |   | ||||||||
City: | PHOENIX | ||||||||
State: | AZ | ||||||||
PostalCode: | 850233415 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6025649603 | ||||||||
FaxNumber: | 6028630387 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/23/2006 | ||||||||
LastUpdateDate: | 10/05/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | EDICK | ||||||||
AuthorizedOfficialFirstName: | SUSAN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | MC ASSISTANT | ||||||||
AuthorizedOfficialTelephone: | 6788923774 | ||||||||
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) |   |
No ID Information.