Healthcare Provider Details

I. General information

NPI: 1821077686
Provider Name (Legal Business Name): SHAD L WHEATLEY OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2006
Last Update Date: 11/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

843 W STUART DR APT 7
HILLSVILLE VA
24343-1555
US

IV. Provider business mailing address

843 W STUART DR APT 7
HILLSVILLE VA
24343-1555
US

V. Phone/Fax

Practice location:
  • Phone: 276-728-9323
  • Fax: 276-728-0400
Mailing address:
  • Phone: 276-728-9323
  • Fax: 276-728-0400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618001276
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: