Provider Demographics
NPI:1407820210
Name:EYE PHYSICIANS OF SOUTHWEST VIRGINIA PC
Entity Type:Organization
Organization Name:EYE PHYSICIANS OF SOUTHWEST VIRGINIA PC
Other - Org Name:EYE PHYSICIANS OPTICAL CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:TRENT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:276-682-3118
Mailing Address - Street 1:340 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ABINGDON
Mailing Address - State:VA
Mailing Address - Zip Code:24210-2624
Mailing Address - Country:US
Mailing Address - Phone:276-628-3118
Mailing Address - Fax:276-628-8342
Practice Address - Street 1:340 W MAIN ST
Practice Address - Street 2:
Practice Address - City:ABINGDON
Practice Address - State:VA
Practice Address - Zip Code:24210-2624
Practice Address - Country:US
Practice Address - Phone:276-628-3118
Practice Address - Fax:276-628-8342
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EYE PHYSICIANS OF SOUTHWEST VIRGINIA PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-02-16
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0221430001OtherDMERC
VA009280928Medicaid
VA0221430002OtherDMERC