Provider Demographics
NPI:1639328768
Name:PREMIER VISION GROUP
Entity Type:Organization
Organization Name:PREMIER VISION GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTICIAN/OFFICER MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:775-746-8884
Mailing Address - Street 1:9700 S MCCARRAN BLVD
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89523-9203
Mailing Address - Country:US
Mailing Address - Phone:775-746-8884
Mailing Address - Fax:775-746-5316
Practice Address - Street 1:9700 S MCCARRAN BLVD
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89523-9203
Practice Address - Country:US
Practice Address - Phone:775-746-8884
Practice Address - Fax:775-746-5316
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-12
Last Update Date:2008-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVOD278152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV410030899OtherMEDICARE RAILROAD
NV410030899OtherMEDICARE RAILROAD
NV0588190001Medicare NSC
NVVOD278Medicare PIN