Provider Demographics
NPI:1013296581
Name:REPKO FAMILY VISION CENTER, PLLC
Entity Type:Organization
Organization Name:REPKO FAMILY VISION CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:G
Authorized Official - Last Name:REPKO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:276-690-2345
Mailing Address - Street 1:241 GATEWAY PLZ
Mailing Address - Street 2:SUITE 106
Mailing Address - City:GATE CITY
Mailing Address - State:VA
Mailing Address - Zip Code:24251-3350
Mailing Address - Country:US
Mailing Address - Phone:276-690-2345
Mailing Address - Fax:
Practice Address - Street 1:241 GATEWAY PLZ
Practice Address - Street 2:SUITE 106
Practice Address - City:GATE CITY
Practice Address - State:VA
Practice Address - Zip Code:24251-3350
Practice Address - Country:US
Practice Address - Phone:276-690-2345
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-15
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010355982Medicaid
VA010128404Medicaid
VAA806Medicare PIN