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General NPI Number Information
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NPI Number | 1477924231
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Entity Type | Organization
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Legal Business Name | BUENA VISTA OPTICAL
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Dates
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Enumeration Date | 10/19/2015
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Last Update Date | 10/19/2015
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Provider Practice Location Address
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Address Line | 300 E OSBORN RD SUITE 100
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City | PHOENIX
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State | AZ
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Zip | 85012-2325
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Country | US
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Telephone | 602-285-9215
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Fax |
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Provider Business Mailing Address
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Address Line | 300 E OSBORN RD SUITE 100
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City | PHOENIX
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State | AZ
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Zip | 85012-2325
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Country | US
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Telephone | 602-285-9215
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | ROBERT WAYNE TINKER
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Credential | LICENSED OPTICIAN
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Telephone | 602-285-9215
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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 | 1067E
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License Number State | AZ
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