Provider Demographics
NPI:1790200624
Name:ADVANCED VISION GROUP, INC.
Entity Type:Organization
Organization Name:ADVANCED VISION GROUP, INC.
Other - Org Name:ADVANCED VISION OPTOMETRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ERICA
Authorized Official - Middle Name:
Authorized Official - Last Name:WU
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:530-902-0271
Mailing Address - Street 1:2655 CLEVELAND AVE STE A
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-2779
Mailing Address - Country:US
Mailing Address - Phone:707-542-8883
Mailing Address - Fax:707-546-7787
Practice Address - Street 1:2655 CLEVELAND AVE STE A
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-2779
Practice Address - Country:US
Practice Address - Phone:707-542-8883
Practice Address - Fax:707-546-7787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-11
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14545152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty