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	156FX1800X	Optician

General Provider Information

NPI Number	:	1487167540
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	:

Provider Business Practice Location Address
First Line	:	432 N CAPITOL AVE
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95133-1938
Country	:	US
Telephone Number	:	408-964-4128
Fax Number	:	408-929-2546

Authorized Official
Title or Position	:	MDG CARE PROVIDER NETWORK SPVSR
Name	:	LEAHANN RENE VAUGHN
Credential	:
Telephone Number	:	470-448-2782

Provider Enumeration Date	:	11/13/2017
Last Update Date	:	11/13/2017

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