Provider Demographics
NPI:1518328616
Name:VINAVONG, LISA JO HOUSTON (LDO)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:JO HOUSTON
Last Name:VINAVONG
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:MRS
Other - First Name:LISA
Other - Middle Name:JO
Other - Last Name:HOUSTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2234 PALMYRA RD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31701-1322
Mailing Address - Country:US
Mailing Address - Phone:229-485-9264
Mailing Address - Fax:229-888-3688
Practice Address - Street 1:2234 PALMYRA RD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31701-1322
Practice Address - Country:US
Practice Address - Phone:229-485-9264
Practice Address - Fax:229-888-3688
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-16
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALDO002657156FC0801X, 156FX1800X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
No156FC0801XEye and Vision Services ProvidersTechnician/TechnologistContact Lens Fitter
No332H00000XSuppliersEyewear Supplier