Provider Demographics
NPI:1326109331
Name:MOUNTAINEER OPTICAL INC
Entity Type:Organization
Organization Name:MOUNTAINEER OPTICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:PENNY
Authorized Official - Middle Name:J
Authorized Official - Last Name:DOYLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-636-7046
Mailing Address - Street 1:116 3RD ST
Mailing Address - Street 2:
Mailing Address - City:ELKINS
Mailing Address - State:WV
Mailing Address - Zip Code:26241
Mailing Address - Country:US
Mailing Address - Phone:304-636-7046
Mailing Address - Fax:304-636-7046
Practice Address - Street 1:116 3RD ST
Practice Address - Street 2:
Practice Address - City:ELKINS
Practice Address - State:WV
Practice Address - Zip Code:26241
Practice Address - Country:US
Practice Address - Phone:304-636-7046
Practice Address - Fax:304-636-7046
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0151814000Medicaid
WV0151814000Medicaid