Provider Demographics
NPI:1023005139
Name:ROANOKE VALLEY CENTER FOR SIGHT LLC
Entity Type:Organization
Organization Name:ROANOKE VALLEY CENTER FOR SIGHT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGED CARE COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:STACI
Authorized Official - Middle Name:E
Authorized Official - Last Name:RUNYON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-855-3554
Mailing Address - Street 1:PO BOX 1789
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24008-1789
Mailing Address - Country:US
Mailing Address - Phone:540-378-5276
Mailing Address - Fax:
Practice Address - Street 1:438 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153-3610
Practice Address - Country:US
Practice Address - Phone:540-855-3554
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-04
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAOH667261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007603380Medicaid
VADB8339Medicare PIN
VA490004971Medicare PIN
VA007603380Medicaid