Provider Demographics
NPI:1336216498
Name:LAWRENCE M MINARDI
Entity Type:Organization
Organization Name:LAWRENCE M MINARDI
Other - Org Name:EYE CENTER OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:MINARDI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-343-6219
Mailing Address - Street 1:500 DONNALLY ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-1648
Mailing Address - Country:US
Mailing Address - Phone:304-346-0292
Mailing Address - Fax:304-343-1423
Practice Address - Street 1:500 DONNALLY ST
Practice Address - Street 2:SUITE 101
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-1648
Practice Address - Country:US
Practice Address - Phone:304-346-0292
Practice Address - Fax:304-343-1423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0151307000Medicaid
0217080001Medicare PIN
WV0151307000Medicaid