Provider Demographics
NPI:1679690754
Name:DR. RICHARD C. REBUCK, OD
Entity Type:Organization
Organization Name:DR. RICHARD C. REBUCK, OD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:CARL
Authorized Official - Last Name:REBUCK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:304-263-4747
Mailing Address - Street 1:255 APPALOOSA DR
Mailing Address - Street 2:
Mailing Address - City:FALLING WATERS
Mailing Address - State:WV
Mailing Address - Zip Code:25419-3854
Mailing Address - Country:US
Mailing Address - Phone:304-263-4747
Mailing Address - Fax:304-263-2935
Practice Address - Street 1:800 FOXCROFT AVE
Practice Address - Street 2:STE 914
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401-1829
Practice Address - Country:US
Practice Address - Phone:304-263-4747
Practice Address - Fax:304-263-2935
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV971-OD152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810009839Medicaid
WV3810009839Medicaid