Provider Demographics
NPI:1578590733
Name:EYE LAB VISION CENTER, INC.
Entity Type:Organization
Organization Name:EYE LAB VISION CENTER, INC.
Other - Org Name:THE OPTICAL SHOP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GRADY
Authorized Official - Middle Name:
Authorized Official - Last Name:STONE
Authorized Official - Suffix:II
Authorized Official - Credentials:LDO
Authorized Official - Phone:334-480-4015
Mailing Address - Street 1:2011 HIGHWAY 280 BYPASS
Mailing Address - Street 2:
Mailing Address - City:PHENIX CITY
Mailing Address - State:AL
Mailing Address - Zip Code:36867
Mailing Address - Country:US
Mailing Address - Phone:334-480-4015
Mailing Address - Fax:334-448-9918
Practice Address - Street 1:2011 HIGHWAY 280 BYPASS
Practice Address - Street 2:
Practice Address - City:PHENIX CITY
Practice Address - State:AL
Practice Address - Zip Code:36867
Practice Address - Country:US
Practice Address - Phone:334-480-4015
Practice Address - Fax:334-448-9918
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-26
Last Update Date:2020-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529907970Medicaid
AL051551360Medicare ID - Type Unspecified
AL529907970Medicaid
ALL244Medicare PIN
AL4478950001Medicare NSC