Provider Demographics
NPI:1477753838
Name:LAUGHLIN AND WADE, OPTOMETRISTS
Entity Type:Organization
Organization Name:LAUGHLIN AND WADE, OPTOMETRISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:J
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:WADE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:304-366-2020
Mailing Address - Street 1:405 LOCUST AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554-4717
Mailing Address - Country:US
Mailing Address - Phone:304-366-2020
Mailing Address - Fax:
Practice Address - Street 1:405 LOCUST AVE
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-4717
Practice Address - Country:US
Practice Address - Phone:304-366-2020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-23
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV646OD152W00000X
WV729OD152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0012623000Medicaid
WVLA9217081Medicare PIN
WV0313430001Medicare NSC