Provider Demographics
NPI:1275508079
Name:ADVANCE VISION MEDICAL, INC.
Entity Type:Organization
Organization Name:ADVANCE VISION MEDICAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:KAYE
Authorized Official - Last Name:SALATKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-573-9385
Mailing Address - Street 1:30856 GROESBECK HWY
Mailing Address - Street 2:B
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-1580
Mailing Address - Country:US
Mailing Address - Phone:586-573-9385
Mailing Address - Fax:586-582-0165
Practice Address - Street 1:30856 GROESBECK HWY
Practice Address - Street 2:B
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-1580
Practice Address - Country:US
Practice Address - Phone:586-573-9385
Practice Address - Fax:586-582-0165
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-23
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3181705Medicaid
MI71020000E00162OtherOXYGEN
1039130001Medicare NSC
MI71020000E00162OtherOXYGEN