Provider Demographics
NPI:1871028209
Name:VISTAR EYE CENTER, INC
Entity Type:Organization
Organization Name:VISTAR EYE CENTER, INC
Other - Org Name:VISTAR ROCKY MOUNT OPTICAL
Other - Org Type:Other Name
Authorized Official - Title/Position:MANAGED CARE
Authorized Official - Prefix:
Authorized Official - First Name:STACI
Authorized Official - Middle Name:ELAINE
Authorized Official - Last Name:RUNYON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-855-3554
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:540-855-5100
Mailing Address - Fax:540-342-4373
Practice Address - Street 1:395 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:VA
Practice Address - Zip Code:24151-1710
Practice Address - Country:US
Practice Address - Phone:540-855-5100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-24
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618001837152W00000X
332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear Supplier
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty