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General NPI Number Information
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NPI Number | 1104102946
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Entity Type | Organization
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Legal Business Name | ADVANCED HEALTH CONCEPTS
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Dates
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Enumeration Date | 10/25/2011
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Last Update Date | 10/23/2013
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Provider Practice Location Address
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Address Line | 11500 MIDLOTHIAN TPKE OUTSIDE JC PENNEY
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City | NORTH CHESTERFIELD
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State | VA
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Zip | 23235-4780
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Country | US
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Telephone | 804-457-8733
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 73293
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City | NORTH CHESTERFIELD
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State | VA
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Zip | 23235-8029
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Country | US
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Telephone | 917-304-7854
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. LISA M BENNETT
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Credential | O.D.
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Telephone | 917-304-7854
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 06128002036
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License Number State | VA
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