Healthcare Provider Details

I. General information

NPI: 1578651097
Provider Name (Legal Business Name): COMMONWEALTH VISION CENTER P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 10/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1447 SOUTH MAIN STREET
BLACKSTONE VA
23824
US

IV. Provider business mailing address

1447 SOUTH MAIN STREET
BLACKSTONE VA
23824-2626
US

V. Phone/Fax

Practice location:
  • Phone: 434-292-6393
  • Fax: 434-292-3266
Mailing address:
  • Phone: 434-292-6393
  • Fax: 434-292-3266

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618000199
License Number StateVA

VIII. Authorized Official

Name: LEONARD BRINKLEY WHITESIDE III
Title or Position: PRESIDENT
Credential: OD
Phone: 434-292-6393