=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710966049
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCED VISION CENTERS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/13/2006
-----------------------------------------------------
Last Update Date | 02/22/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 446 3RD AVE W
-----------------------------------------------------
City | DICKINSON
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-225-2020
-----------------------------------------------------
Fax | 701-483-5879
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 967
-----------------------------------------------------
City | DICKINSON
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58602-0967
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-225-2020
-----------------------------------------------------
Fax | 701-483-5879
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST/CO-OWNER
-----------------------------------------------------
Name | MR. JAY C NELSON
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 701-225-2020
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------