Provider Demographics
NPI:1528304458
Name:GAMMOH PREMIER VISION LLC
Entity type:Organization
Organization Name:GAMMOH PREMIER VISION LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:NATALY
Authorized Official - Middle Name:
Authorized Official - Last Name:GAMMOH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:787-930-0418
Mailing Address - Street 1:556 N EASTERN AVE STE A
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89101-3453
Mailing Address - Country:US
Mailing Address - Phone:702-388-9400
Mailing Address - Fax:702-385-1116
Practice Address - Street 1:556 N EASTERN AVE STE A
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89101-3453
Practice Address - Country:US
Practice Address - Phone:702-388-9400
Practice Address - Fax:702-385-1116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-20
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV716152W00000X
TX8041T302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX345273201Medicaid
NV1851668339Medicaid