Basic Information
| Provider Information | |||||||||
| NPI: | 1558302489 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NATIONAL VISION, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | VISION CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2435 COMMERCE AVE | ||||||||
| Address2: | BLDG 2200 | ||||||||
| City: | DULUTH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300964980 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708223600 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 550 EMILY DR | ||||||||
| Address2: | |||||||||
| City: | CLARKSBURG | ||||||||
| State: | WV | ||||||||
| PostalCode: | 263015508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046222494 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2006 | ||||||||
| LastUpdateDate: | 02/02/2017 | ||||||||
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| AuthorizedOfficialLastName: | VAUGHN | ||||||||
| AuthorizedOfficialFirstName: | LEAHANN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGED CARE SALES COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 7708223600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332H00000X | Y | Suppliers | Eyewear Supplier (Equipment, not the service) |
ID Information
| ID | Type | State | Issuer | Description | 0151470000 | 05 | WV | MEDICAID |