Provider Demographics
NPI:1134281355
Name:STARCHVICK OPTICAL INC
Entity Type:Organization
Organization Name:STARCHVICK OPTICAL INC
Other - Org Name:ADVANCED VISION WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:STARCHVICK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:541-779-1392
Mailing Address - Street 1:1251 E MCANDREWS RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-6497
Mailing Address - Country:US
Mailing Address - Phone:541-779-1392
Mailing Address - Fax:541-779-6531
Practice Address - Street 1:1251 E MCANDREWS RD
Practice Address - Street 2:SUITE 100
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-6497
Practice Address - Country:US
Practice Address - Phone:541-779-1392
Practice Address - Fax:541-779-6531
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1563ATI152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR271176Medicaid
OR212666OtherEYEMED
OR=========OtherEIN
OR4352280001Medicare NSC
OR=========OtherEIN