Provider Demographics
NPI:1417071002
Name:DR BEATTIE FORK UNION OFFICE
Entity Type:Organization
Organization Name:DR BEATTIE FORK UNION OFFICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:WILLS
Authorized Official - Last Name:BEATTIE
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:434-842-3364
Mailing Address - Street 1:PO BOX 517
Mailing Address - Street 2:
Mailing Address - City:FORK UNION
Mailing Address - State:VA
Mailing Address - Zip Code:23055
Mailing Address - Country:US
Mailing Address - Phone:434-842-3364
Mailing Address - Fax:434-842-3362
Practice Address - Street 1:4321 JAMES MADISON HWY
Practice Address - Street 2:SUITE 2
Practice Address - City:FORK UNION
Practice Address - State:VA
Practice Address - Zip Code:23055-2025
Practice Address - Country:US
Practice Address - Phone:434-842-3364
Practice Address - Fax:434-842-3362
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
022131OtherBLUE CROSS