Provider Demographics
NPI:1427602382
Name:STACIE LAYNE VIRDEN OD PA
Entity Type:Organization
Organization Name:STACIE LAYNE VIRDEN OD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STACIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:VIRDEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:254-776-8119
Mailing Address - Street 1:1000 W STATE HIGHWAY 6 STE 210
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76712-3788
Mailing Address - Country:US
Mailing Address - Phone:254-776-8119
Mailing Address - Fax:
Practice Address - Street 1:1000 W STATE HIGHWAY 6 STE 210
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-3788
Practice Address - Country:US
Practice Address - Phone:254-776-8119
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-30
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty