MEDICARE: ENVISION OPTICS 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	332H00000X	Eyewear Supplier

General Provider Information

NPI Number	:	1710467857
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ENVISION OPTICS LLC

Provider Business Mailing Address
First Line	:	1943 PLEASANT HILL RD
Second Line	:
City	:	DULUTH
State	:	GA
Zip	:	30096-4625
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1943 PLEASANT HILL RD
Second Line	:
City	:	DULUTH
State	:	GA
Zip	:	30096
Country	:	US
Telephone Number	:	404-448-4745
Fax Number	:	404-228-0855

Authorized Official
Title or Position	:	CREDENTIALING MANAGER
Name	:	JACKIE BENNETT
Credential	:
Telephone Number	:	505-365-0979

Provider Enumeration Date	:	08/17/2018
Last Update Date	:	02/17/2021

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