Provider Demographics
NPI:1538341839
Name:ADVANCED VISION CENTER PLLC
Entity type:Organization
Organization Name:ADVANCED VISION CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:BENTON
Authorized Official - Last Name:LYON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-649-2450
Mailing Address - Street 1:PO BOX 1965
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39441-1965
Mailing Address - Country:US
Mailing Address - Phone:601-649-2450
Mailing Address - Fax:601-649-0556
Practice Address - Street 1:705 SAWMILL RD
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-3937
Practice Address - Country:US
Practice Address - Phone:601-649-2450
Practice Address - Fax:601-649-0556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-29
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS200001782Medicaid