Provider Demographics
NPI:1184775041
Name:EYE CENTER OF GREENBRIER VALLEY INC
Entity type:Organization
Organization Name:EYE CENTER OF GREENBRIER VALLEY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE
Authorized Official - Prefix:
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:
Authorized Official - Last Name:LIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-793-3937
Mailing Address - Street 1:3942 DAVIS STUART RD
Mailing Address - Street 2:
Mailing Address - City:RONCEVERTE
Mailing Address - State:WV
Mailing Address - Zip Code:24970-0260
Mailing Address - Country:US
Mailing Address - Phone:304-793-3937
Mailing Address - Fax:304-793-2203
Practice Address - Street 1:3942 DAVIS STUART RD
Practice Address - Street 2:
Practice Address - City:RONCEVERTE
Practice Address - State:WV
Practice Address - Zip Code:24970-0260
Practice Address - Country:US
Practice Address - Phone:304-793-3937
Practice Address - Fax:304-793-2203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1100XEye and Vision Services ProvidersTechnician/TechnologistOphthalmicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810003698Medicaid
WV3810003698Medicaid
4855360001Medicare NSC