Provider Demographics
NPI:1881643583
Name:JESSE BEN MIZE III & CHRISTIE MIZE PTR
Entity Type:Organization
Organization Name:JESSE BEN MIZE III & CHRISTIE MIZE PTR
Other - Org Name:RAVENSWOOD EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VIRGINIA
Authorized Official - Middle Name:E
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-273-2020
Mailing Address - Street 1:706 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:RAVENSWOOD
Mailing Address - State:WV
Mailing Address - Zip Code:26164-1772
Mailing Address - Country:US
Mailing Address - Phone:304-273-2020
Mailing Address - Fax:
Practice Address - Street 1:706 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:RAVENSWOOD
Practice Address - State:WV
Practice Address - Zip Code:26164-1772
Practice Address - Country:US
Practice Address - Phone:304-273-2020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-09
Last Update Date:2010-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV924-OD152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001267200Medicaid
WV0653170001Medicare NSC
WV001267200Medicaid
WV9265721Medicare PIN
WVDO1772Medicare PIN