=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992998637
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCED VISION, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/27/2007
-----------------------------------------------------
Last Update Date | 08/27/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4200 MERCHANT ST SUITE 103
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65203-5816
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-447-2020
-----------------------------------------------------
Fax | 573-447-2042
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4200 MERCHANT ST SUITE 103
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65203-5816
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-447-2020
-----------------------------------------------------
Fax | 573-447-2042
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER, LLC
-----------------------------------------------------
Name | DR. SAHBA JALALI
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 573-447-2020
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 2001006508
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------