Provider Demographics
NPI:1295188050
Name:VISTA OPTICAL
Entity Type:Organization
Organization Name:VISTA OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LEAHANN
Authorized Official - Middle Name:RENE
Authorized Official - Last Name:VAUGHN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:470-448-2782
Mailing Address - Street 1:2435 COMMERCE AVE
Mailing Address - Street 2:BLDG 2200
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-4980
Mailing Address - Country:US
Mailing Address - Phone:770-822-3600
Mailing Address - Fax:
Practice Address - Street 1:102 W OCTAGON ST
Practice Address - Street 2:BLDG 77B
Practice Address - City:CANNON AFB
Practice Address - State:NM
Practice Address - Zip Code:88103-5207
Practice Address - Country:US
Practice Address - Phone:575-904-1001
Practice Address - Fax:575-784-9722
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NATIONAL VISION, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-07-18
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty