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General NPI Number Information
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NPI Number | 1265943450
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Entity Type | Organization
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Legal Business Name | INNOVATIVE VISION THERAPY CENTER
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Dates
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Enumeration Date | 10/16/2017
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Last Update Date | 10/16/2017
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Provider Practice Location Address
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Address Line | 3215 MARTIN LUTHER KING JR BLVD STE O
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City | ANDERSON
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State | SC
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Zip | 29625-1715
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Country | US
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Telephone | 864-540-8404
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Fax |
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Provider Business Mailing Address
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Address Line | 3215 MARTIN LUTHER KING JR BLVD STE O
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City | ANDERSON
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State | SC
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Zip | 29625-1715
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Country | US
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Telephone | 864-540-8404
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | TABITHA JOHNSON
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Credential |
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Telephone | 864-540-8404
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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 | 152WV0400X
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Taxonomy Name | Vision Therapy Optometrist
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License Number |
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License Number State | SC
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