Provider Demographics
NPI:1033470935
Name:EDGEWATER EYECARE LLC
Entity Type:Organization
Organization Name:EDGEWATER EYECARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:NICHOLAS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:757-513-5408
Mailing Address - Street 1:4700 KILGORE AVE
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-2057
Mailing Address - Country:US
Mailing Address - Phone:757-825-1849
Mailing Address - Fax:757-827-3261
Practice Address - Street 1:4700 KILGORE AVE
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-2057
Practice Address - Country:US
Practice Address - Phone:757-825-1849
Practice Address - Fax:757-827-3261
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-06
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618001947152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty