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General NPI Number Information
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NPI Number | 1225108830
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Entity Type | Organization
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Legal Business Name | RIVERSIDE OPTICAL INC
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Dates
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Enumeration Date | 11/09/2006
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Last Update Date | 05/03/2016
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Provider Practice Location Address
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Address Line | 535 JACK WARNER PKWY NE STE B2
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City | TUSCALOOSA
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State | AL
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Zip | 35404-5715
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Country | US
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Telephone | 205-554-0107
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Fax | 205-554-0198
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Provider Business Mailing Address
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Address Line | 535 JACK WARNER PKWY NE STE B2
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City | TUSCALOOSA
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State | AL
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Zip | 35404-5715
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Country | US
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Telephone | 205-554-0107
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Fax | 205-554-0198
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Authorized Official
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Title or Position | PHYSICIAN OWNER
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Name | DR. ERNES VAN JOHNSON
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Credential | M.D.
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Telephone | 205-556-4440
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number |
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License Number State |
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