Healthcare Provider Details

I. General information

NPI: 1790098325
Provider Name (Legal Business Name): OPTOMETRIC SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2010
Last Update Date: 08/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

792 OLD CUTLER RD
VIRGINIA BEACH VA
23454-6050
US

IV. Provider business mailing address

792 OLD CUTLER RD
VIRGINIA BEACH VA
23454-6050
US

V. Phone/Fax

Practice location:
  • Phone: 757-705-3082
  • Fax: 757-340-0891
Mailing address:
  • Phone: 757-705-3082
  • Fax: 757-340-0891

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618001612
License Number StateVA

VIII. Authorized Official

Name: DR. JENNIFER BRAUN BOWERS
Title or Position: PRESIDENT
Credential: O.D.
Phone: 757-705-3082