Healthcare Provider Details

I. General information

NPI: 1194224501
Provider Name (Legal Business Name): ENVISION OPTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2018
Last Update Date: 02/17/2021
Certification Date: 02/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1790 SCENIC HWY N
SNELLVILLE GA
30078-2134
US

IV. Provider business mailing address

1943 PLEASANT HILL RD
DULUTH GA
30096-4625
US

V. Phone/Fax

Practice location:
  • Phone: 448-448-4745
  • Fax: 470-300-9087
Mailing address:
  • Phone: 404-448-4745
  • Fax: 561-828-8367

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JACKIE BENNETT
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 561-433-6009