Provider Demographics
NPI:1568452456
Name:SHENANDOAH OPTICAL INC
Entity Type:Organization
Organization Name:SHENANDOAH OPTICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:540-667-2220
Mailing Address - Street 1:230 SHENANDOAH ST
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:VA
Mailing Address - Zip Code:22664-1051
Mailing Address - Country:US
Mailing Address - Phone:540-459-8313
Mailing Address - Fax:540-459-9452
Practice Address - Street 1:230 SHENANDOAH ST
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:VA
Practice Address - Zip Code:22664-1051
Practice Address - Country:US
Practice Address - Phone:540-459-8313
Practice Address - Fax:540-459-9452
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-24
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1101001190332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA009280758Medicaid
VA0398870001Medicare NSC