Provider Demographics
NPI:1760060743
Name:TINA ANSARI OD & ASSOCIATES, LLC
Entity Type:Organization
Organization Name:TINA ANSARI OD & ASSOCIATES, LLC
Other - Org Name:LUMEN EYE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:ANSARI
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:703-594-9099
Mailing Address - Street 1:13934 ESTATE MANOR DR UNIT J
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20155-5951
Mailing Address - Country:US
Mailing Address - Phone:703-594-9099
Mailing Address - Fax:
Practice Address - Street 1:13934 ESTATE MANOR DR UNIT J
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:VA
Practice Address - Zip Code:20155-5951
Practice Address - Country:US
Practice Address - Phone:804-605-9821
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-31
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty