Provider Demographics
NPI:1861477051
Name:SHELL OPTICAL OF VIRGINIA, INC.
Entity Type:Organization
Organization Name:SHELL OPTICAL OF VIRGINIA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:W
Authorized Official - Last Name:SHELL
Authorized Official - Suffix:
Authorized Official - Credentials:ABOC
Authorized Official - Phone:757-934-2422
Mailing Address - Street 1:2463 PRUDEN BLVD
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-4235
Mailing Address - Country:US
Mailing Address - Phone:757-934-2422
Mailing Address - Fax:757-934-2640
Practice Address - Street 1:2463 PRUDEN BLVD
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-4235
Practice Address - Country:US
Practice Address - Phone:757-934-2422
Practice Address - Fax:757-934-2640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1101000541332H00000X
VA1101001778332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0995540001Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER