Provider Demographics
NPI:1417905852
Name:ADVANCED VISION CENTERS LTD
Entity Type:Organization
Organization Name:ADVANCED VISION CENTERS LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:
Authorized Official - Last Name:LICHOTA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:586-268-4466
Mailing Address - Street 1:5714 15 MILE RD
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48310-5705
Mailing Address - Country:US
Mailing Address - Phone:586-268-4466
Mailing Address - Fax:586-268-9530
Practice Address - Street 1:5714 15 MILE RD
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48310-5705
Practice Address - Country:US
Practice Address - Phone:586-268-4466
Practice Address - Fax:586-268-9530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-05
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIU21459Medicare UPIN