Provider Demographics
NPI:1578646923
Name:FAMILY VISION SOURCE, LLC
Entity Type:Organization
Organization Name:FAMILY VISION SOURCE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CURTIS
Authorized Official - Middle Name:P
Authorized Official - Last Name:DECHANT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:520-663-5393
Mailing Address - Street 1:7475 E TANQUE VERDE RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85715-3477
Mailing Address - Country:US
Mailing Address - Phone:520-663-5393
Mailing Address - Fax:520-663-1023
Practice Address - Street 1:7475 E TANQUE VERDE RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85715-3477
Practice Address - Country:US
Practice Address - Phone:520-663-5393
Practice Address - Fax:520-663-1023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-21
Last Update Date:2010-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ78639Medicare ID - Type Unspecified
AZP00120739Medicare PIN
AZ5134350001Medicare NSC