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	:	1770214389
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	:	770-822-3600
Fax Number	:

Provider Business Practice Location Address
First Line	:	7190 N ACADEMY BLVD
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80920-3185
Country	:	US
Telephone Number	:	719-653-8405
Fax Number	:

Authorized Official
Title or Position	:	MANAGED CARE STORE ENROLLMENT
Name	:	JULIE GARRISON
Credential	:
Telephone Number	:	770-822-3600

Provider Enumeration Date	:	06/23/2022
Last Update Date	:	06/23/2022

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