Healthcare Provider Details

I. General information

NPI: 1871123943
Provider Name (Legal Business Name): LOIS HERMANN PHILLIPS O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2020
Last Update Date: 01/17/2020
Certification Date: 01/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 GAMEBIRD CT
MANAKIN SABOT VA
23103
US

IV. Provider business mailing address

9 GAMEBIRD CT
MANAKIN SABOT VA
23103
US

V. Phone/Fax

Practice location:
  • Phone: 804-305-7792
  • Fax:
Mailing address:
  • Phone: 804-305-7792
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618000877
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number0618000877
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: