Provider Demographics
NPI:1568839975
Name:NOVA OPTOMETRY LLC
Entity Type:Organization
Organization Name:NOVA OPTOMETRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRINCIPAL MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOO
Authorized Official - Middle Name:H
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:571-338-9956
Mailing Address - Street 1:5612 SHEALS LN
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20120-1988
Mailing Address - Country:US
Mailing Address - Phone:571-338-9956
Mailing Address - Fax:703-497-2202
Practice Address - Street 1:12643 GALVESTON CT
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20112-8673
Practice Address - Country:US
Practice Address - Phone:571-338-9956
Practice Address - Fax:703-497-2202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-02
Last Update Date:2015-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618001515152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty