Provider Demographics
NPI:1306379003
Name:PROVISION EYE CARE, LLC
Entity type:Organization
Organization Name:PROVISION EYE CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:
Authorized Official - Last Name:MELTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-756-2020
Mailing Address - Street 1:10208 STAPLES MILL RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060
Mailing Address - Country:US
Mailing Address - Phone:804-756-2020
Mailing Address - Fax:804-447-6885
Practice Address - Street 1:10208 STAPLES MILL RD
Practice Address - Street 2:
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23060
Practice Address - Country:US
Practice Address - Phone:804-756-2020
Practice Address - Fax:804-447-6885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-10
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618001394152WC0802X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Multi-Specialty