Provider Demographics
NPI:1629195029
Name:ALVERNON OPTICAL, INC.
Entity Type:Organization
Organization Name:ALVERNON OPTICAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF RETAIL
Authorized Official - Prefix:
Authorized Official - First Name:STACIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:DECKER
Authorized Official - Suffix:
Authorized Official - Credentials:LDO
Authorized Official - Phone:520-327-6215
Mailing Address - Street 1:7123 E TANQUE VERDE RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85715-3431
Mailing Address - Country:US
Mailing Address - Phone:520-296-4157
Mailing Address - Fax:520-296-4418
Practice Address - Street 1:7123 E TANQUE VERDE RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85715-3431
Practice Address - Country:US
Practice Address - Phone:520-296-4157
Practice Address - Fax:520-296-4418
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ813332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ413906Medicaid
AZ0328860007Medicare ID - Type Unspecified