MEDICARE: NATIONAL VISION INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist

General Provider Information

NPI Number	:	1366099574
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NATIONAL VISION INC

Provider Business Mailing Address
First Line	:	2435 COMMERCE AVE BLDG 2200
Second Line	:
City	:	DULUTH
State	:	GA
Zip	:	30096-4980
Country	:	US
Telephone Number	:	800-571-5202
Fax Number	:	770-220-1969

Provider Business Practice Location Address
First Line	:	1624 N BECHTLE AVE
Second Line	:
City	:	SPRINGFIELD
State	:	OH
Zip	:	45504-1572
Country	:	US
Telephone Number	:	937-398-7179
Fax Number	:	937-325-9785

Authorized Official
Title or Position	:	MANAGED CARE SALES MANAGER
Name	:	LEAHANN RENE VAUGHN
Credential	:
Telephone Number	:	470-448-2782

Provider Enumeration Date	:	08/22/2019
Last Update Date	:	08/22/2019

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