Provider Demographics
NPI:1700829553
Name:COUNTRYSIDE OPTICAL
Entity Type:Organization
Organization Name:COUNTRYSIDE OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:FRANCISCO
Authorized Official - Middle Name:
Authorized Official - Last Name:ALTAMIRANO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:703-444-8500
Mailing Address - Street 1:20 PIDGEON HILL DR
Mailing Address - Street 2:SUITE 107
Mailing Address - City:STERLING
Mailing Address - State:VA
Mailing Address - Zip Code:20165-6154
Mailing Address - Country:US
Mailing Address - Phone:703-444-8500
Mailing Address - Fax:703-406-3801
Practice Address - Street 1:20 PIDGEON HILL DR
Practice Address - Street 2:SUITE 107
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20165-6154
Practice Address - Country:US
Practice Address - Phone:703-444-8500
Practice Address - Fax:703-406-3801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1101-001527156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty