Provider Demographics
NPI:1750672622
Name:NEW RIVER EYE CARE FAMILY OPTOMETRY PC
Entity Type:Organization
Organization Name:NEW RIVER EYE CARE FAMILY OPTOMETRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:M
Authorized Official - Last Name:LANE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:540-921-4116
Mailing Address - Street 1:700 WENONAH AVE
Mailing Address - Street 2:
Mailing Address - City:PEARISBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24134-1638
Mailing Address - Country:US
Mailing Address - Phone:540-921-4116
Mailing Address - Fax:540-921-4118
Practice Address - Street 1:700 WENONAH AVE
Practice Address - Street 2:
Practice Address - City:PEARISBURG
Practice Address - State:VA
Practice Address - Zip Code:24134-1638
Practice Address - Country:US
Practice Address - Phone:540-921-4116
Practice Address - Fax:540-921-4118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-27
Last Update Date:2011-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA9798Medicare PIN