Healthcare Provider Details

I. General information

NPI: 1215470836
Provider Name (Legal Business Name): PRECISION VISION AZ LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2016
Last Update Date: 11/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 OLD COURT RD SUITE 204
PIKESVILLE MD
21208-2800
US

IV. Provider business mailing address

1135 REGINA DR
HALETHORPE MD
21227-2342
US

V. Phone/Fax

Practice location:
  • Phone: 410-653-2400
  • Fax: 602-535-3165
Mailing address:
  • Phone: 410-653-2400
  • Fax: 602-535-3165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. SELVIN GNANAKKAN
Title or Position: OPTOMETRIST/PRESIDENT
Credential: OD
Phone: 602-770-9300