MEDICARE: NATIONWIDE VISION CENTER, LLC

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	156FX1800X	Optician

General Provider Information

NPI Number	:	1467523282
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NATIONWIDE VISION CENTER, LLC

Provider Business Mailing Address
First Line	:	955 W SOUTHERN AVE STE 101
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85210-4903
Country	:	US
Telephone Number	:	480-961-1865
Fax Number	:	480-893-8172

Provider Business Practice Location Address
First Line	:	21001 N TATUM BLVD # 741570
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85050-4206
Country	:	US
Telephone Number	:	480-538-9811
Fax Number	:	480-538-9809

Authorized Official
Title or Position	:	CHIEF MEDICAL OFFICER
Name	:	JOSEPH PRAVOOT GIRA
Credential	:	MD
Telephone Number	:	314-909-0633

Provider Enumeration Date	:	11/13/2006
Last Update Date	:	12/20/2022

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