Healthcare Provider Details

I. General information

NPI: 1376613976
Provider Name (Legal Business Name): NATIONWIDE VISION CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 12/16/2022
Certification Date: 12/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1781 E STATE ROUTE 69 SUITE 55
PRESCOTT AZ
86301-5666
US

IV. Provider business mailing address

955 W SOUTHERN AVE STE 101
MESA AZ
85210-4903
US

V. Phone/Fax

Practice location:
  • Phone: 928-776-3096
  • Fax: 928-776-7917
Mailing address:
  • Phone: 480-961-1865
  • Fax: 480-893-8172

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State

VIII. Authorized Official

Name: JOSEPH PRAVOOT GIRA
Title or Position: CHIEF MEDICAL OFFICER
Credential: MD
Phone: 314-909-0633