Provider Demographics
NPI:1144694852
Name:IMPERIAL VISION
Entity type:Organization
Organization Name:IMPERIAL VISION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTONIO
Authorized Official - Middle Name:LEMONT
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:267-625-3379
Mailing Address - Street 1:3964 N SMEDLEY ST
Mailing Address - Street 2:APT C
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19140-3421
Mailing Address - Country:US
Mailing Address - Phone:267-625-3379
Mailing Address - Fax:
Practice Address - Street 1:3964 NORTH SMEDLEY ST.
Practice Address - Street 2:APT C
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140
Practice Address - Country:US
Practice Address - Phone:267-625-3379
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-18
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA000000001332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier