Provider Demographics
NPI:1972614584
Name:ALVERNON OPTICAL, INC.
Entity Type:Organization
Organization Name:ALVERNON OPTICAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT OF RETAIL
Authorized Official - Prefix:MRS
Authorized Official - First Name:STACIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:DECKER
Authorized Official - Suffix:
Authorized Official - Credentials:LICENSED OPTICIAN
Authorized Official - Phone:520-327-6215
Mailing Address - Street 1:440 N ALVERNON WAY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85711-1958
Mailing Address - Country:US
Mailing Address - Phone:520-327-6215
Mailing Address - Fax:520-327-6546
Practice Address - Street 1:440 N ALVERNON WAY
Practice Address - Street 2:SUITE 101
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85711-1958
Practice Address - Country:US
Practice Address - Phone:520-327-6215
Practice Address - Fax:520-327-6546
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ813332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ155475Medicaid
AZ0328860001Medicare ID - Type UnspecifiedLOCATION MAIN OFFICE