=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144919622
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NATIONAL VISION INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/02/2023
-----------------------------------------------------
Last Update Date | 05/02/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8120 GOV RITCHIE HWY
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21122-6916
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-942-9083
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2435 COMMERCE AVE BLDG 2200
-----------------------------------------------------
City | DULUTH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30096-4980
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-822-3600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGED CARE STORE ENROLLMENT
-----------------------------------------------------
Name | JULIE GARRISON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 770-822-3600
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------