| Organization Name: | HERITAGE PARK VISION SOURCE |
| NPI Number: | 1851417117 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | RUSSELL LAVERTY (OPTOMETRIST) |
| Mailing Address: | 6912 E Reno Ave Suite 101 Midwest City |
| State: | OK US |
| Postal Code: | 731102162 |
| Phone Number: | 4057322277 |
| Fax Number: | 4057374776 |
| NPI Enumeration Date: | 03/21/2007 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 332H00000X |
| License Number: | 818 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | OK |
| Taxonomy Type: | Suppliers |
| Taxonomy Classification: | Eyewear Supplier (Equipment, not the service) |
| Taxonomy Specialization: | |
| Taxonomy Definition: | An organization that provides spectacles, contact lenses, and other vision enhancement devices prescribed by an optometrist or ophthalmologist. |