Healthcare Provider Details

I. General information

NPI: 1477698819
Provider Name (Legal Business Name): CHESTERFIELD OPTOMETRIC CENTER, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 07/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9440 IRONBRIDGE ROAD
CHESTERFIELD VA
23832-9123
US

IV. Provider business mailing address

9440 IRONBRIDGE ROAD PO BOX 1118
CHESTERFIELD VA
23832-9123
US

V. Phone/Fax

Practice location:
  • Phone: 804-748-4877
  • Fax:
Mailing address:
  • Phone: 804-748-4877
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0603000042
License Number StateVA

VIII. Authorized Official

Name: ANN WILLIAMS
Title or Position: INSURANCE
Credential:
Phone: 804-748-4877