Provider Demographics
NPI:1427155472
Name:ENVISION PROFESSIONAL GROUP, PLLC
Entity type:Organization
Organization Name:ENVISION PROFESSIONAL GROUP, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:B
Authorized Official - Last Name:BLEVINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:276-783-5157
Mailing Address - Street 1:1020 TERRACE DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MARION
Mailing Address - State:VA
Mailing Address - Zip Code:24354-4392
Mailing Address - Country:US
Mailing Address - Phone:276-783-5157
Mailing Address - Fax:276-783-5159
Practice Address - Street 1:1020 TERRACE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:MARION
Practice Address - State:VA
Practice Address - Zip Code:24354
Practice Address - Country:US
Practice Address - Phone:276-783-5157
Practice Address - Fax:276-783-5159
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SMYTH COUNTY EYE ASSOCIATES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-20
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000072261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA9234080Medicaid
VA009234080Medicaid
VA410001076Medicare ID - Type Unspecified
VA1316580001Medicare NSC