Provider Demographics
NPI:1982705448
Name:WALLY BETTON OD LLC
Entity Type:Organization
Organization Name:WALLY BETTON OD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WALLY
Authorized Official - Middle Name:
Authorized Official - Last Name:BETTON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:276-647-3766
Mailing Address - Street 1:4244 VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24078-1935
Mailing Address - Country:US
Mailing Address - Phone:276-647-3766
Mailing Address - Fax:276-647-4279
Practice Address - Street 1:4244 VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:COLLINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24078-1935
Practice Address - Country:US
Practice Address - Phone:276-647-3766
Practice Address - Fax:276-647-4279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2012-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000209152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010332770Medicaid
VA010337399Medicaid
VA010145660Medicaid
VA012289W99Medicare PIN
VA010332770Medicaid
VA010145660Medicaid
VA011436W99Medicare PIN
VAC09499Medicare PIN