Provider Demographics
NPI:1710078225
Name:BRONDSTATERS OPTICAL AMERICA
Entity Type:Organization
Organization Name:BRONDSTATERS OPTICAL AMERICA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:BRADFORD
Authorized Official - Last Name:BRONDSTATER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-263-2020
Mailing Address - Street 1:800 FOXCROFT AVENUE
Mailing Address - Street 2:SUITE 914
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25401
Mailing Address - Country:US
Mailing Address - Phone:304-263-2020
Mailing Address - Fax:304-263-2935
Practice Address - Street 1:800 FOXCROFT AVENUE
Practice Address - Street 2:SUITE 914
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401
Practice Address - Country:US
Practice Address - Phone:304-263-2020
Practice Address - Fax:304-263-2935
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVWV10170OtherVBA
WV338639OtherCLARITY VISION
WV3810002980Medicaid
WVVA0031OtherEYE MED
WV16784OtherAVESIS
WV501161OtherNVA
WV3810002980Medicaid