=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003861402
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NATIONAL VISION, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2006
-----------------------------------------------------
Last Update Date | 02/08/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 120 COMMERCIAL PKWY
-----------------------------------------------------
City | BRANFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06405-2537
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-483-1876
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 951336
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75395-1336
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MC ASST
-----------------------------------------------------
Name | SUSAN EDICK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 678-892-3774
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------