Provider Demographics
NPI:1649469115
Name:PIEDMONT VISION CARE PLLC
Entity type:Organization
Organization Name:PIEDMONT VISION CARE PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:MANTINI
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:309-222-8275
Mailing Address - Street 1:10660 CRESTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20109-3432
Mailing Address - Country:US
Mailing Address - Phone:703-369-3937
Mailing Address - Fax:703-369-7147
Practice Address - Street 1:10660 CRESTWOOD DR
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20109-3432
Practice Address - Country:US
Practice Address - Phone:703-369-3937
Practice Address - Fax:703-369-7147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-19
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000305152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC08357Medicare PIN
VA0461900001Medicare NSC