Provider Demographics
NPI:1922357136
Name:MOORE VISION CENTER NORTH, PLLC
Entity Type:Organization
Organization Name:MOORE VISION CENTER NORTH, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTY
Authorized Official - Middle Name:B
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:304-369-9100
Mailing Address - Street 1:467 MAIN ST
Mailing Address - Street 2:SUITE 401
Mailing Address - City:MADISON
Mailing Address - State:WV
Mailing Address - Zip Code:25130-2200
Mailing Address - Country:US
Mailing Address - Phone:304-369-9100
Mailing Address - Fax:304-369-9105
Practice Address - Street 1:2700 MOUNTAINEER BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-9442
Practice Address - Country:US
Practice Address - Phone:304-744-2713
Practice Address - Fax:304-744-0704
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-04
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1064OD152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty