Provider Demographics
NPI:1831164250
Name:GREGMAR INC
Entity type:Organization
Organization Name:GREGMAR INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:RUMBAUGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-453-4072
Mailing Address - Street 1:PO BOX 488
Mailing Address - Street 2:
Mailing Address - City:CEREDO
Mailing Address - State:WV
Mailing Address - Zip Code:25507-0488
Mailing Address - Country:US
Mailing Address - Phone:304-453-4072
Mailing Address - Fax:304-453-6172
Practice Address - Street 1:#1 FAIRWOOD LANE
Practice Address - Street 2:
Practice Address - City:CEREDO
Practice Address - State:WV
Practice Address - Zip Code:25507
Practice Address - Country:US
Practice Address - Phone:304-453-4072
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-20
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV000290362OtherMOUNTAIN STATE BLUE CROSS
WV=========OtherFEDERAL EMPOYER ID
WV0151173000Medicaid
WV=========OtherFEDERAL EMPOYER ID