Provider Demographics
NPI:1538468764
Name:FAMILY EYEDOCTORS PLLC
Entity Type:Organization
Organization Name:FAMILY EYEDOCTORS PLLC
Other - Org Name:FAMILY EYEDOCTORS
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JILL
Authorized Official - Middle Name:
Authorized Official - Last Name:SHOWALTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-295-5025
Mailing Address - Street 1:1500 GRAND CENTRAL AVE STE 112
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:WV
Mailing Address - Zip Code:26105-1079
Mailing Address - Country:US
Mailing Address - Phone:304-295-5025
Mailing Address - Fax:
Practice Address - Street 1:1500 GRAND CENTRAL AVE STE 112
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:WV
Practice Address - Zip Code:26105-1079
Practice Address - Country:US
Practice Address - Phone:304-295-5025
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-28
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV939-OD152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVA530OtherMEDICARE PTAN