Healthcare Provider Details

I. General information

NPI: 1184140618
Provider Name (Legal Business Name): VISTAR EYE CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2017
Last Update Date: 08/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

749 E CHURCH ST
MARTINSVILLE VA
24112-3106
US

IV. Provider business mailing address

PO BOX 1789
ROANOKE VA
24008-1789
US

V. Phone/Fax

Practice location:
  • Phone: 276-632-7205
  • Fax: 276-632-6366
Mailing address:
  • Phone: 276-632-7205
  • Fax: 276-632-6366

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618001837
License Number StateVA

VIII. Authorized Official

Name: STACI ELAINE RUNYON
Title or Position: MANAGED CARE
Credential:
Phone: 540-855-3554