Provider Demographics
NPI:1922571645
Name:MOUNTAIN STATE VISION CARE PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:MOUNTAIN STATE VISION CARE PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:AUSTIN
Authorized Official - Middle Name:G
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:304-663-1283
Mailing Address - Street 1:206 WINGATE DRIVE
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15205
Mailing Address - Country:US
Mailing Address - Phone:304-723-4222
Mailing Address - Fax:304-723-4222
Practice Address - Street 1:400 THREE SPRINGS DRIVE
Practice Address - Street 2:
Practice Address - City:WEIRTON
Practice Address - State:WV
Practice Address - Zip Code:26062
Practice Address - Country:US
Practice Address - Phone:304-723-4222
Practice Address - Fax:304-723-4222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-04
Last Update Date:2019-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty