Provider Demographics
NPI:1558636613
Name:LAVI VISION PC
Entity Type:Organization
Organization Name:LAVI VISION PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JULIA
Authorized Official - Middle Name:N
Authorized Official - Last Name:TA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:510-300-5800
Mailing Address - Street 1:2934 PEGASUS CT
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-8042
Mailing Address - Country:US
Mailing Address - Phone:510-300-5810
Mailing Address - Fax:
Practice Address - Street 1:2325 W INTERSTATE 20
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-3927
Practice Address - Country:US
Practice Address - Phone:510-300-5810
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-21
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7696TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2871717Medicaid
TXTXB141982OtherMEDICARE PTAN