Provider Demographics
NPI:1821275157
Name:DAVIS OPTICAL CENTERS
Entity Type:Organization
Organization Name:DAVIS OPTICAL CENTERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:RDO
Authorized Official - Phone:775-826-1666
Mailing Address - Street 1:5053 S MCCARRAN BLVD
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-6545
Mailing Address - Country:US
Mailing Address - Phone:775-826-1666
Mailing Address - Fax:775-826-1729
Practice Address - Street 1:5053 S MCCARRAN BLVD
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-6545
Practice Address - Country:US
Practice Address - Phone:775-826-1666
Practice Address - Fax:775-826-1729
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-29
Last Update Date:2012-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV102156FC0800X, 156FC0801X, 156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
No156FC0800XEye and Vision Services ProvidersTechnician/TechnologistContact LensGroup - Single Specialty
No156FC0801XEye and Vision Services ProvidersTechnician/TechnologistContact Lens FitterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV004116010Medicaid
NV004116010Medicaid