Basic Information
| Provider Information | |||||||||
| NPI: | 1528468303 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NATIONWIDE VISION CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 220 N MCKEMY AVE | ||||||||
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| City: | CHANDLER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852262654 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 85 W COMBS RD | ||||||||
| Address2: | SUITE 108 | ||||||||
| City: | SAN TAN VALLEY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 851409105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809611865 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2014 | ||||||||
| LastUpdateDate: | 10/11/2019 | ||||||||
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| AuthorizedOfficialLastName: | HAYES | ||||||||
| AuthorizedOfficialFirstName: | VINCENT | ||||||||
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| AuthorizedOfficialTitleorPosition: | SECRETARY AND EXECUTIVE VP | ||||||||
| AuthorizedOfficialTelephone: | 4808354470 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 156FX1800X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Technician/Technologist | Optician |
ID Information
| ID | Type | State | Issuer | Description | 1326472945 | 01 | AZ | BILLING NPI | OTHER |