Provider Demographics
NPI:1861629917
Name:GREENBRIER PHYSICIANS, INC. OPTICAL SHOP
Entity Type:Organization
Organization Name:GREENBRIER PHYSICIANS, INC. OPTICAL SHOP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:D
Authorized Official - Last Name:TROUT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-647-1140
Mailing Address - Street 1:200 MAPLEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:RONCEVERTE
Mailing Address - State:WV
Mailing Address - Zip Code:24970-1334
Mailing Address - Country:US
Mailing Address - Phone:304-647-1147
Mailing Address - Fax:304-647-3006
Practice Address - Street 1:200 MAPLEWOOD AVE
Practice Address - Street 2:
Practice Address - City:RONCEVERTE
Practice Address - State:WV
Practice Address - Zip Code:24970-1334
Practice Address - Country:US
Practice Address - Phone:304-647-1147
Practice Address - Fax:304-647-3006
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GREENBRIER PHYSICIANS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-06-16
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1100XEye and Vision Services ProvidersTechnician/TechnologistOphthalmicGroup - Multi-Specialty
No156F00000XEye and Vision Services ProvidersTechnician/TechnologistGroup - Multi-Specialty
No156FC0800XEye and Vision Services ProvidersTechnician/TechnologistContact LensGroup - Multi-Specialty
No156FC0801XEye and Vision Services ProvidersTechnician/TechnologistContact Lens FitterGroup - Multi-Specialty
No156FX1101XEye and Vision Services ProvidersTechnician/TechnologistOphthalmic AssistantGroup - Multi-Specialty