Provider Demographics
NPI:1710991708
Name:VIRGINIA EYECARE CLINIC, LLC
Entity Type:Organization
Organization Name:VIRGINIA EYECARE CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:JOY
Authorized Official - Last Name:UMLANDT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:276-935-2292
Mailing Address - Street 1:1193 PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:GRUNDY
Mailing Address - State:VA
Mailing Address - Zip Code:24614-6780
Mailing Address - Country:US
Mailing Address - Phone:276-935-2292
Mailing Address - Fax:276-935-2993
Practice Address - Street 1:1193 PLAZA DR
Practice Address - Street 2:
Practice Address - City:GRUNDY
Practice Address - State:VA
Practice Address - Zip Code:24614-6780
Practice Address - Country:US
Practice Address - Phone:276-935-4558
Practice Address - Fax:276-935-2993
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2023-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0601002211152W00000X
VA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA143512OtherANTHEM
WV9200061001Medicaid
VA009237348Medicaid
VAC08631Medicare Oscar/Certification
WV9200061001Medicaid