Provider Demographics
NPI:1104102946
Name:ADVANCED HEALTH CONCEPTS
Entity type:Organization
Organization Name:ADVANCED HEALTH CONCEPTS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:M
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:917-304-7854
Mailing Address - Street 1:PO BOX 73293
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23235-8029
Mailing Address - Country:US
Mailing Address - Phone:917-304-7854
Mailing Address - Fax:
Practice Address - Street 1:11500 MIDLOTHIAN TPKE
Practice Address - Street 2:OUTSIDE JC PENNEY
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23235-4780
Practice Address - Country:US
Practice Address - Phone:804-457-8733
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ADVANCED HEALTH CONCEPTS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-10-25
Last Update Date:2013-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA06128002036152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty