Provider Demographics
NPI:1609165653
Name:GREENBRIAR VISION CENTER, INC
Entity Type:Organization
Organization Name:GREENBRIAR VISION CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:MAROTTA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:703-322-2020
Mailing Address - Street 1:13029 LEE JACKSON MEMORIAL HWY
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-2001
Mailing Address - Country:US
Mailing Address - Phone:703-322-2020
Mailing Address - Fax:703-322-1221
Practice Address - Street 1:13029 LEE JACKSON MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-2001
Practice Address - Country:US
Practice Address - Phone:703-322-2020
Practice Address - Fax:703-322-1221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-30
Last Update Date:2012-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000088261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6496690001Medicare NSC
228378Medicare PIN