Provider Demographics
NPI:1386650729
Name:SOUTHSIDE OPTICAL CENTER LLC
Entity Type:Organization
Organization Name:SOUTHSIDE OPTICAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RIPON
Authorized Official - Middle Name:W
Authorized Official - Last Name:LAROCHE
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:434-392-9555
Mailing Address - Street 1:PO BOX 506
Mailing Address - Street 2:
Mailing Address - City:FARMVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23901-0506
Mailing Address - Country:US
Mailing Address - Phone:434-392-9555
Mailing Address - Fax:434-392-1524
Practice Address - Street 1:1511 W THIRD ST
Practice Address - Street 2:
Practice Address - City:FARMVILLE
Practice Address - State:VA
Practice Address - Zip Code:23901
Practice Address - Country:US
Practice Address - Phone:434-392-9555
Practice Address - Fax:434-392-1524
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA528207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA009280553Medicaid
VA1146180001Medicare NSC