Provider Demographics
NPI:1366524910
Name:ADVANTAGE VISION CENTER
Entity type:Organization
Organization Name:ADVANTAGE VISION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:NEWSOME
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:704-375-3935
Mailing Address - Street 1:1016 S CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-4002
Mailing Address - Country:US
Mailing Address - Phone:704-375-3935
Mailing Address - Fax:704-333-7238
Practice Address - Street 1:1016 S CHURCH ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-4002
Practice Address - Country:US
Practice Address - Phone:704-375-3935
Practice Address - Fax:704-333-7238
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1087152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0203QOtherBLUE CROSS BLUE SHIELD
NC4418381OtherAETNA
NC6382063OtherCIGNA
NC8909651Medicaid
NC108363OtherWELLPATH
NC295758OtherMEDCOST
NC295758OtherMEDCOST