Healthcare Provider Details

I. General information

NPI: 1861477051
Provider Name (Legal Business Name): SHELL OPTICAL OF VIRGINIA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2463 PRUDEN BLVD
SUFFOLK VA
23434-4235
US

IV. Provider business mailing address

2463 PRUDEN BLVD
SUFFOLK VA
23434-4235
US

V. Phone/Fax

Practice location:
  • Phone: 757-934-2422
  • Fax: 757-934-2640
Mailing address:
  • Phone: 757-934-2422
  • Fax: 757-934-2640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number1101001778
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number1101000541
License Number StateVA

VIII. Authorized Official

Name: MR. GERALD W SHELL
Title or Position: OPTICIAN
Credential: ABOC
Phone: 757-934-2422