| Name | Value |
|---|---|
| PROVIDER TYPE | Eye and Vision Services Providers |
| CLASSIFICATION | Technician/Technologist |
| AREA OF SPECIALIZATION | Ophthalmic |
| STATUS | Active |
| VA CODE | V060500 |
| X12 CODE | 156FX1100X |
| INDIVIDUAL/NON | INDIVIDUAL |
| MASTER ENTRY FOR VUID | YES |
| VUID | 5252627 |
| EFFECTIVE DATE/TIME |
|