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General NPI Number Information
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NPI Number | 1366567877
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Entity Type | Organization
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Legal Business Name | VISION BOUTIQUE INC
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Dates
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Enumeration Date | 03/21/2007
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Last Update Date | 03/25/2008
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Provider Practice Location Address
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Address Line | 212 W DIXON BLVD
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City | SHELBY
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State | NC
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Zip | 28152-6522
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Country | US
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Telephone | 704-482-9883
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Fax | 704-482-9842
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Provider Business Mailing Address
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Address Line | 212 W DIXON BLVD
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City | SHELBY
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State | NC
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Zip | 28152-6522
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Country | US
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Telephone | 704-482-9883
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Fax | 704-482-9842
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Authorized Official
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Title or Position | OWNER
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Name | MR. JIMMY L MORTON
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Credential | OPTICIAN
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Telephone | 704-482-9883
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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 | 200001385282
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License Number State | NC
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