Healthcare Provider Details

I. General information

NPI: 1477924231
Provider Name (Legal Business Name): BUENA VISTA OPTICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2015
Last Update Date: 10/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 E OSBORN RD SUITE 100
PHOENIX AZ
85012-2325
US

IV. Provider business mailing address

300 E OSBORN RD SUITE 100
PHOENIX AZ
85012-2325
US

V. Phone/Fax

Practice location:
  • Phone: 602-285-9215
  • Fax:
Mailing address:
  • Phone: 602-285-9215
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number1067E
License Number StateAZ

VIII. Authorized Official

Name: ROBERT WAYNE TINKER
Title or Position: MANAGER
Credential: LICENSED OPTICIAN
Phone: 602-285-9215