Provider Demographics
NPI:1841706934
Name:PREMIER VISION LLC
Entity type:Organization
Organization Name:PREMIER VISION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER - OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTINE
Authorized Official - Middle Name:THAO
Authorized Official - Last Name:SAM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:504-234-5678
Mailing Address - Street 1:3601 VALLEYVIEW DR
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34746-2895
Mailing Address - Country:US
Mailing Address - Phone:504-234-5678
Mailing Address - Fax:407-350-5883
Practice Address - Street 1:703 N MAIN ST
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744-5265
Practice Address - Country:US
Practice Address - Phone:504-234-5678
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-27
Last Update Date:2017-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC5446152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty