1063587590 NPI number — VISION SOURCE, INC.

Table of content: (NPI 1063587590)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063587590 NPI number — VISION SOURCE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VISION SOURCE, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063587590
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/03/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5590 CHALKVILLE RD
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
BIRMINGHAM
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35235-8636
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-520-9002
Provider Business Mailing Address Fax Number:
205-520-9064

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5590 CHALKVILLE RD STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BIRMINGHAM
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35235-8637
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
205-520-9002
Provider Business Practice Location Address Fax Number:
205-520-9064
Provider Enumeration Date:
11/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FEW
Authorized Official First Name:
GARY
Authorized Official Middle Name:
C
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
205-520-9002

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  07005076 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 051523183 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 051523259 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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