Healthcare Provider Details

I. General information

NPI: 1285806281
Provider Name (Legal Business Name): CONSOLIDATED VISION GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2008
Last Update Date: 01/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6375 ULALI DRIVE
KEIZER OR
97303
US

IV. Provider business mailing address

296 GRAYSON HIGHWAY
LAWRENCEVILLE GA
30046
US

V. Phone/Fax

Practice location:
  • Phone: 503-428-5096
  • Fax: 503-463-7253
Mailing address:
  • Phone: 770-822-3600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MR. SHAWN T. MONAHAN
Title or Position: DIRECTOR, MANAGED CARE
Credential:
Phone: 678-892-3283