Provider Demographics
NPI:1609829480
Name:ADVANCED VISION CARE CENTER, LLC
Entity Type:Organization
Organization Name:ADVANCED VISION CARE CENTER, LLC
Other - Org Name:MASOUD GHOHESTANI OD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MASOUD
Authorized Official - Middle Name:
Authorized Official - Last Name:GHOHESTANT
Authorized Official - Suffix:
Authorized Official - Credentials:O D
Authorized Official - Phone:812-926-4836
Mailing Address - Street 1:PO BOX 4174
Mailing Address - Street 2:
Mailing Address - City:LAWRENEBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47025-4174
Mailing Address - Country:US
Mailing Address - Phone:812-926-4836
Mailing Address - Fax:812-926-4651
Practice Address - Street 1:100 SYCAMORE ESTATES DR
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IN
Practice Address - Zip Code:47001
Practice Address - Country:US
Practice Address - Phone:812-926-4836
Practice Address - Fax:812-926-4651
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261Q00000X
KY1446DT152W00000X
IN18003027A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300024163Medicaid
OH2278664Medicaid
OH9368302Medicare PIN
IN200468820AMedicaid
U75303Medicare UPIN