Provider Demographics
NPI:1912029786
Name:MPG LLC
Entity Type:Organization
Organization Name:MPG LLC
Other - Org Name:SHENANDOAH EYE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:P
Authorized Official - Last Name:GOWEN
Authorized Official - Suffix:SR
Authorized Official - Credentials:OD
Authorized Official - Phone:540-434-6622
Mailing Address - Street 1:1870 RESERVOIR ST
Mailing Address - Street 2:
Mailing Address - City:HARRISONBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22801
Mailing Address - Country:US
Mailing Address - Phone:540-434-6622
Mailing Address - Fax:540-434-4187
Practice Address - Street 1:1870 RESERVOIR ST
Practice Address - Street 2:
Practice Address - City:HARRISONBURG
Practice Address - State:VA
Practice Address - Zip Code:22801-8742
Practice Address - Country:US
Practice Address - Phone:540-434-6622
Practice Address - Fax:540-434-4187
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1831170026Medicaid
U02729Medicare UPIN
VA1831170026Medicaid