Healthcare Provider Details

I. General information

NPI: 1215636428
Provider Name (Legal Business Name): VISIONARY RETAIL MANAGEMENT CA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2023
Last Update Date: 02/27/2023
Certification Date: 02/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3639 RIVERSIDE PLAZA DR STE 518
RIVERSIDE CA
92506-2718
US

IV. Provider business mailing address

175 E HOUSTON ST
SAN ANTONIO TX
78205-2299
US

V. Phone/Fax

Practice location:
  • Phone: 726-444-4172
  • Fax:
Mailing address:
  • Phone: 726-444-4172
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: DOROTHY REYNOLDS
Title or Position: VP NVC RETAIL OPERATIONS
Credential:
Phone: 726-444-4056