Provider Demographics
NPI:1649577859
Name:TEAYS VALLEY EYE CARE
Entity Type:Organization
Organization Name:TEAYS VALLEY EYE CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:J
Authorized Official - Last Name:HENRY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:304-760-8703
Mailing Address - Street 1:3859 TEAYS VALLEY RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:HURRICANE
Mailing Address - State:WV
Mailing Address - Zip Code:25526-9622
Mailing Address - Country:US
Mailing Address - Phone:304-760-8703
Mailing Address - Fax:304-760-8704
Practice Address - Street 1:3859 TEAYS VALLEY RD
Practice Address - Street 2:SUITE 2
Practice Address - City:HURRICANE
Practice Address - State:WV
Practice Address - Zip Code:25526-9622
Practice Address - Country:US
Practice Address - Phone:304-760-8703
Practice Address - Fax:304-760-8704
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-24
Last Update Date:2011-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV0936OD152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0149908000Medicaid
WVU59019Medicare UPIN