Provider Demographics
NPI:1699825778
Name:INNOVISION PRACTICE GROUP PA
Entity Type:Organization
Organization Name:INNOVISION PRACTICE GROUP PA
Other - Org Name:INNOVISION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:SARNO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:727-489-0500
Mailing Address - Street 1:PO BOX 3365
Mailing Address - Street 2:
Mailing Address - City:SEMINOLE
Mailing Address - State:FL
Mailing Address - Zip Code:33775-3365
Mailing Address - Country:US
Mailing Address - Phone:727-489-0500
Mailing Address - Fax:727-489-0508
Practice Address - Street 1:10785 102ND AVE
Practice Address - Street 2:
Practice Address - City:SEMINOLE
Practice Address - State:FL
Practice Address - Zip Code:33778-4211
Practice Address - Country:US
Practice Address - Phone:727-209-3937
Practice Address - Fax:727-394-7393
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2008-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAK621Medicare PIN