Healthcare Provider Details

I. General information

NPI: 1518328616
Provider Name (Legal Business Name): LISA JO HOUSTON VINAVONG LDO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MRS. LISA JO HOUSTON

II. Dates (important events)

Enumeration Date: 03/16/2016
Last Update Date: 03/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2234 PALMYRA RD
ALBANY GA
31701-1322
US

IV. Provider business mailing address

2234 PALMYRA RD
ALBANY GA
31701-1322
US

V. Phone/Fax

Practice location:
  • Phone: 229-485-9264
  • Fax: 229-888-3688
Mailing address:
  • Phone: 229-485-9264
  • Fax: 229-888-3688

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code156FC0801X
TaxonomyContact Lens Fitter
License NumberLDO002657
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License NumberLDO002657
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License NumberLDO002657
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: