MEDICARE: NATIONAL VISION INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist

General Provider Information

NPI Number	:	1043860281
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NATIONAL VISION INC

Provider Business Mailing Address
First Line	:	2435 COMMERCE AVE BLDG 2200
Second Line	:
City	:	DULUTH
State	:	GA
Zip	:	30096-4980
Country	:	US
Telephone Number	:	800-571-5202
Fax Number	:	770-220-1969

Provider Business Practice Location Address
First Line	:	1278 TOWN CENTRE DR STE 155
Second Line	:
City	:	EAGAN
State	:	MN
Zip	:	55123-6404
Country	:	US
Telephone Number	:	612-851-0208
Fax Number	:	651-686-2940

Authorized Official
Title or Position	:	MGD CARE PROVIDER NETWORK SPRVSR
Name	:	LEAHANN RENE VAUGHN
Credential	:
Telephone Number	:	470-448-2782

Provider Enumeration Date	:	09/19/2019
Last Update Date	:	09/19/2019

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Directions to “NATIONAL VISION INC ” Practice Location

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