Provider Demographics
NPI:1043300239
Name:ADVANCED VISION GROUP, LLC
Entity type:Organization
Organization Name:ADVANCED VISION GROUP, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:W
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-512-2161
Mailing Address - Street 1:39189 OAK ST
Mailing Address - Street 2:
Mailing Address - City:PEARL RIVER
Mailing Address - State:LA
Mailing Address - Zip Code:70452-5031
Mailing Address - Country:US
Mailing Address - Phone:958-863-2704
Mailing Address - Fax:985-863-3207
Practice Address - Street 1:3900 VETERANS MEMORIAL BLVD
Practice Address - Street 2:STE. 100
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70002-5634
Practice Address - Country:US
Practice Address - Phone:504-620-2020
Practice Address - Fax:504-455-2011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA145261QS0132X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0132XAmbulatory Health Care FacilitiesClinic/CenterOphthalmologic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA7855740OtherAETNA
LAP00184030OtherRAILROAD MEDICARE
LA1471941Medicaid
LA11094Medicare ID - Type UnspecifiedPROVIDER NUMBER