Provider Demographics
NPI:1639279680
Name:VIRGINIA OPTICAL CENTER INC
Entity Type:Organization
Organization Name:VIRGINIA OPTICAL CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTICIAN OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:POWELL
Authorized Official - Last Name:FISHER
Authorized Official - Suffix:JR
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:804-861-3005
Mailing Address - Street 1:1980 S SYCAMORE ST
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23805-2729
Mailing Address - Country:US
Mailing Address - Phone:804-861-3005
Mailing Address - Fax:804-861-8243
Practice Address - Street 1:1980 S SYCAMORE ST
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23805-2729
Practice Address - Country:US
Practice Address - Phone:804-861-3005
Practice Address - Fax:804-861-8243
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2016-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1101001155156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA009282572Medicaid
VAVA1155OtherEYE MED VISION CARE
VA061380OtherANTHEM
VA009282572Medicaid