Provider Demographics
NPI:1740424126
Name:VISTAR EYE CENTER
Entity Type:Organization
Organization Name:VISTAR EYE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:P
Authorized Official - Last Name:COWAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-855-5123
Mailing Address - Street 1:PO BOX 1789
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24008-1789
Mailing Address - Country:US
Mailing Address - Phone:540-855-5139
Mailing Address - Fax:540-342-4373
Practice Address - Street 1:548 BLUE RIDGE AVE
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:VA
Practice Address - Zip Code:24523-2604
Practice Address - Country:US
Practice Address - Phone:540-855-5139
Practice Address - Fax:540-342-4373
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-29
Last Update Date:2009-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1156332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier