Provider Demographics
NPI:1255486882
Name:SPECTRUM OPTICAL PLLC
Entity Type:Organization
Organization Name:SPECTRUM OPTICAL PLLC
Other - Org Name:SPECTRUM OPTICAL LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:HENRY
Authorized Official - Last Name:GOELLNER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:304-599-7034
Mailing Address - Street 1:1257 PINEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-2713
Mailing Address - Country:US
Mailing Address - Phone:304-599-7034
Mailing Address - Fax:304-599-5483
Practice Address - Street 1:1257 PINEVIEW DR
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-2713
Practice Address - Country:US
Practice Address - Phone:304-599-7034
Practice Address - Fax:304-599-5483
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810002839Medicaid
WVSP9353631Medicare ID - Type Unspecified
WVDB0324Medicare ID - Type UnspecifiedRAILROAD MEDICARE
WV4131450001Medicare NSC