Provider Demographics
NPI:1508280801
Name:ANTONINI OCULAR PROSTHETICS, LLC
Entity Type:Organization
Organization Name:ANTONINI OCULAR PROSTHETICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:ANTONINI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-594-0719
Mailing Address - Street 1:2208 SURREY DR
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-2926
Mailing Address - Country:US
Mailing Address - Phone:304-594-0719
Mailing Address - Fax:304-241-1858
Practice Address - Street 1:1 STADIUM DR
Practice Address - Street 2:WVU EYE INSTITUTE
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505
Practice Address - Country:US
Practice Address - Phone:304-594-0719
Practice Address - Fax:304-241-1858
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ANTONINI OCULAR PROSTHETICS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-02-07
Last Update Date:2014-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1700XEye and Vision Services ProvidersTechnician/TechnologistOcularistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV381002299Medicaid