Provider Demographics
NPI:1295259554
Name:PRO VISION OPTICAL
Entity type:Organization
Organization Name:PRO VISION OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:NORMA
Authorized Official - Middle Name:
Authorized Official - Last Name:KARRAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-269-9099
Mailing Address - Street 1:1300 W MALONEY AVE STE 208
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-3325
Mailing Address - Country:US
Mailing Address - Phone:505-722-2294
Mailing Address - Fax:505-726-2871
Practice Address - Street 1:1300 W MALONEY AVE STE 208
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-3325
Practice Address - Country:US
Practice Address - Phone:505-722-2294
Practice Address - Fax:505-726-2871
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier