Provider Demographics
NPI:1407360134
Name:DANIEL KINGSLEY O.D., P.C.
Entity Type:Organization
Organization Name:DANIEL KINGSLEY O.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:KINGSLEY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:434-315-4036
Mailing Address - Street 1:100 NORTH VIRGINIA ST
Mailing Address - Street 2:P.O. BOX 303
Mailing Address - City:FARMVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23901
Mailing Address - Country:US
Mailing Address - Phone:434-392-8113
Mailing Address - Fax:434-392-6271
Practice Address - Street 1:100 N VIRGINIA ST
Practice Address - Street 2:
Practice Address - City:FARMVILLE
Practice Address - State:VA
Practice Address - Zip Code:23901-1537
Practice Address - Country:US
Practice Address - Phone:434-392-8113
Practice Address - Fax:434-392-6271
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-16
Last Update Date:2017-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000544152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1417063744Medicaid