Provider Demographics
NPI:1104943729
Name:MEDICAL VISION ASSOCIATES OF NORTHPORT
Entity type:Organization
Organization Name:MEDICAL VISION ASSOCIATES OF NORTHPORT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:HUGH
Authorized Official - Last Name:SUMNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-330-0705
Mailing Address - Street 1:3101 MAIN AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:NORTHPORT
Mailing Address - State:AL
Mailing Address - Zip Code:35476-3111
Mailing Address - Country:US
Mailing Address - Phone:205-330-0705
Mailing Address - Fax:205-330-1750
Practice Address - Street 1:3101 MAIN AVE
Practice Address - Street 2:SUITE C
Practice Address - City:NORTHPORT
Practice Address - State:AL
Practice Address - Zip Code:35476-3111
Practice Address - Country:US
Practice Address - Phone:205-330-0705
Practice Address - Fax:205-330-1750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL4669332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier