MEDICARE: INNOVATIVE 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	152WV0400X	Vision Therapy Optometrist	1393	SC

General Provider Information

NPI Number	:	1538104336
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INNOVATIVE VISION CENTER LLC

Provider Business Mailing Address
First Line	:	7611 HIGHWAY 76
Second Line	:	STE. B
City	:	PENDLETON
State	:	SC
Zip	:	29670-9162
Country	:	US
Telephone Number	:	864-646-3535
Fax Number	:	864-646-3538

Provider Business Practice Location Address
First Line	:	7611 HIGHWAY 76
Second Line	:	STE. B
City	:	PENDLETON
State	:	SC
Zip	:	29670-9162
Country	:	US
Telephone Number	:	864-646-3535
Fax Number	:	864-646-3538

Authorized Official
Title or Position	:	OWNER/SOLE MEMBER
Name	:	DR. FRANK WILLIAM FORGNONI
Credential	:	O.D.
Telephone Number	:	864-646-3535

Provider Enumeration Date	:	06/17/2006
Last Update Date	:	08/22/2020

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