Provider Demographics
NPI:1568612190
Name:NOVA EYE CARE CENTER, LLC
Entity Type:Organization
Organization Name:NOVA EYE CARE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST/ MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:TINA
Authorized Official - Middle Name:VU
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:703-813-8997
Mailing Address - Street 1:3223 DUKE ST STE B3
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22314-4555
Mailing Address - Country:US
Mailing Address - Phone:703-813-8997
Mailing Address - Fax:703-662-5408
Practice Address - Street 1:3223 DUKE ST
Practice Address - Street 2:SUITE B3
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-4586
Practice Address - Country:US
Practice Address - Phone:703-813-8997
Practice Address - Fax:703-662-5408
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-18
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1104014455152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC141094Medicare PIN