Healthcare Provider Details

I. General information

NPI: 1487660221
Provider Name (Legal Business Name): OPTICAL SHOPPE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 05/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3206 CHURCHLAND BLVD
CHESAPEAKE VA
23321-5206
US

IV. Provider business mailing address

3206 CHURCHLAND BLVD
CHESAPEAKE VA
23321-5206
US

V. Phone/Fax

Practice location:
  • Phone: 757-484-0303
  • Fax: 757-484-0515
Mailing address:
  • Phone: 757-484-0303
  • Fax: 757-484-0515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number6005389
License Number StateVA

VIII. Authorized Official

Name: MRS. NICOLE HAWLEY
Title or Position: OFFICE MANAGER
Credential:
Phone: 757-484-0101