Provider Demographics
NPI:1689102923
Name:VAN BUREN OPTICAL, LLC
Entity Type:Organization
Organization Name:VAN BUREN OPTICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:J
Authorized Official - Last Name:VANBUREN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-995-1166
Mailing Address - Street 1:1130 E MISSOURI AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-2712
Mailing Address - Country:US
Mailing Address - Phone:602-995-1166
Mailing Address - Fax:602-995-2390
Practice Address - Street 1:1130 E MISSOURI AVE STE 110
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-2712
Practice Address - Country:US
Practice Address - Phone:602-995-1166
Practice Address - Fax:602-995-2390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-31
Last Update Date:2017-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier