1104270412 NPI number — NATIONWIDE VISION CENTER, INC.

Table of content: (NPI 1104270412)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104270412 NPI number — NATIONWIDE VISION CENTER, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NATIONWIDE VISION CENTER, 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:
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:
1104270412
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/15/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
955 W SOUTHERN AVE STE 101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MESA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85210-4903
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-961-1865
Provider Business Mailing Address Fax Number:
480-893-8172

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3501 E BROADWAY BLVD
Provider Second Line Business Practice Location Address:
INSIDE JCPENNEY
Provider Business Practice Location Address City Name:
TUCSON
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85716-5405
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-881-7248
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/22/2016

Additional Information

Authorized Official

Authorized Official Last Name:
GIRA
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
PRAVOOT
Authorized Official Title or Position:
CHIEF MEDICAL OFFICER
Authorized Official Telephone Number:
314-909-0633

Provider Taxonomy Codes

  • Taxonomy code: 156FX1800X , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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