MEDICARE: ADVANCED VISION, 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	152W00000X	Optometrist	2001006508	MO

General Provider Information

NPI Number	:	1992998637
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADVANCED VISION, LLC

Provider Business Mailing Address
First Line	:	4200 MERCHANT ST
Second Line	:	SUITE 103
City	:	COLUMBIA
State	:	MO
Zip	:	65203-5816
Country	:	US
Telephone Number	:	573-447-2020
Fax Number	:	573-447-2042

Provider Business Practice Location Address
First Line	:	4200 MERCHANT ST
Second Line	:	SUITE 103
City	:	COLUMBIA
State	:	MO
Zip	:	65203-5816
Country	:	US
Telephone Number	:	573-447-2020
Fax Number	:	573-447-2042

Authorized Official
Title or Position	:	OWNER, LLC
Name	:	DR. SAHBA JALALI
Credential	:	OD
Telephone Number	:	573-447-2020

Provider Enumeration Date	:	08/27/2007
Last Update Date	:	08/27/2007

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