Basic Information
| Provider Information | |||||||||
| NPI: | 1770990376 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANCED VISION SURGERY CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2010 BREMO RD STE 128A | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232262444 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8779690392 | ||||||||
| FaxNumber: | 7572202798 | ||||||||
| Practice Location | |||||||||
| Address1: | 5215 MONTICELLO AVE | ||||||||
| Address2: | |||||||||
| City: | WILLIAMSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 231888213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7572294000 | ||||||||
| FaxNumber: | 7572202798 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2014 | ||||||||
| LastUpdateDate: | 03/04/2021 | ||||||||
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| AuthorizedOfficialLastName: | CAMPBELL | ||||||||
| AuthorizedOfficialFirstName: | GLENN | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | OWER/DOCTOR | ||||||||
| AuthorizedOfficialTelephone: | 7572294000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COLONIAL OPHTHALMOLOGY | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 03/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | VA | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | VA-04435 | 01 | VA | CERTIFICATE OF PUBLIC NEED | OTHER |