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General NPI Number Information
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NPI Number | 1174756902
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Entity Type | Organization
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Legal Business Name | GRANITE CITY VISION, INC.
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Dates
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Enumeration Date | 08/27/2009
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Last Update Date | 08/26/2019
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Provider Practice Location Address
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Address Line | 4182 NAMEOKI RD.
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City | GRANITE CITY
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State | IL
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Zip | 62040-2330
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Country | US
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Telephone | 618-876-2438
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Fax | 618-876-2440
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Provider Business Mailing Address
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Address Line | 4182 NAMEOKI RD.
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City | GRANITE CITY
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State | IL
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Zip | 62040-2330
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Country | US
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Telephone | 618-876-2438
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Fax | 618-876-2440
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Authorized Official
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Title or Position | OWNER
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Name | MR. BYRON W. WRIGHT
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Credential |
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Telephone | 618-339-8951
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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 |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 156FC0801X
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Taxonomy Name | Contact Lens Fitter
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 156FX1800X
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Taxonomy Name | Optician
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 305S00000X
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Taxonomy Name | Point of Service
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 305R00000X
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Taxonomy Name | Preferred Provider Organization
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License Number |
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License Number State |
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