Healthcare Provider Details

I. General information

NPI: 1417071002
Provider Name (Legal Business Name): DR BEATTIE FORK UNION OFFICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 10/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4321 JAMES MADISON HWY SUITE 2
FORK UNION VA
23055-2025
US

IV. Provider business mailing address

PO BOX 517
FORK UNION VA
23055
US

V. Phone/Fax

Practice location:
  • Phone: 434-842-3364
  • Fax: 434-842-3362
Mailing address:
  • Phone: 434-842-3364
  • Fax: 434-842-3362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: DR. RUSSELL WILLS BEATTIE JR.
Title or Position: OWNER
Credential:
Phone: 434-842-3364