Healthcare Provider Details

I. General information

NPI: 1679892442
Provider Name (Legal Business Name): PROFESSIONAL VISION ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2010
Last Update Date: 07/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 S VERMONT AVE STE 132-A
OKLAHOMA CITY OK
73108-1042
US

IV. Provider business mailing address

400 S VERMONT AVE STE 132-A
OKLAHOMA CITY OK
73108-1042
US

V. Phone/Fax

Practice location:
  • Phone: 405-947-3937
  • Fax: 405-943-6002
Mailing address:
  • Phone: 405-947-3937
  • Fax: 405-943-6002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code156F00000X
TaxonomyTechnician/Technologist
License Number
License Number State

VIII. Authorized Official

Name: JOE MADORE
Title or Position: GENERAL MANAGER
Credential: ABOC
Phone: 405-947-3937