=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013966340
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCED VISION CENTERS LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/05/2006
-----------------------------------------------------
Last Update Date | 06/17/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 64641 VAN DYKE RD
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48095-2584
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-752-4477
-----------------------------------------------------
Fax | 586-752-3270
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 64641 VAN DYKE RD
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48095-2584
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-752-4477
-----------------------------------------------------
Fax | 586-752-3270
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | FRED LICHOTA
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 586-752-4477
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 4901002788
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------