Healthcare Provider Details

I. General information

NPI: 1861467763
Provider Name (Legal Business Name): TAYLOR E REPKO OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2006
Last Update Date: 04/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 EUCLID AVE STE D
BRISTOL VA
24201-3700
US

IV. Provider business mailing address

241 GATEWAY PLZ STE 106
GATE CITY VA
24251-3350
US

V. Phone/Fax

Practice location:
  • Phone: 276-466-4227
  • Fax:
Mailing address:
  • Phone: 276-690-2345
  • Fax: 276-690-2345

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0601800559
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: