Provider Demographics
NPI:1033239017
Name:THE OPTICAL GALLERY
Entity Type:Organization
Organization Name:THE OPTICAL GALLERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTICIAN OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:SHEILA
Authorized Official - Middle Name:BAXTER
Authorized Official - Last Name:YACKEL
Authorized Official - Suffix:
Authorized Official - Credentials:RO,
Authorized Official - Phone:804-448-0900
Mailing Address - Street 1:17484 D CENTER DRIVE
Mailing Address - Street 2:
Mailing Address - City:RUTHER GLEN
Mailing Address - State:VA
Mailing Address - Zip Code:22546-2839
Mailing Address - Country:US
Mailing Address - Phone:804-448-0900
Mailing Address - Fax:804-448-4470
Practice Address - Street 1:17484 D CENTER DRIVE
Practice Address - Street 2:
Practice Address - City:RUTHER GLEN
Practice Address - State:VA
Practice Address - Zip Code:22546-2839
Practice Address - Country:US
Practice Address - Phone:804-448-0900
Practice Address - Fax:804-448-4470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-31
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1101 002527156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty