Provider Demographics
NPI:1659400596
Name:THE VILLIAGE STORE INC
Entity Type:Organization
Organization Name:THE VILLIAGE STORE INC
Other - Org Name:FAIRBANKS OPTOMETRIC CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:CURTIS
Authorized Official - Last Name:GRAVES
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:907-474-8695
Mailing Address - Street 1:3455 REWAK DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709
Mailing Address - Country:US
Mailing Address - Phone:907-474-8695
Mailing Address - Fax:907-474-8727
Practice Address - Street 1:3455 REWAK DR
Practice Address - Street 2:SUITE 102
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709
Practice Address - Country:US
Practice Address - Phone:907-474-8695
Practice Address - Fax:907-474-8727
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK97152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty