Healthcare Provider Details

I. General information

NPI: 1467766279
Provider Name (Legal Business Name): COLONIAL EYE CARE, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2010
Last Update Date: 12/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5121 CENTER ST SUITE 102
WILLIAMSBURG VA
23188-2686
US

IV. Provider business mailing address

5121 CENTER ST SUITE 102
WILLIAMSBURG VA
23188-2686
US

V. Phone/Fax

Practice location:
  • Phone: 757-903-2633
  • Fax: 757-903-2634
Mailing address:
  • Phone: 757-903-2633
  • Fax: 757-903-2634

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618001521
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number0618001521
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number0615001521
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License Number0618001521
License Number StateVA
# 5
Primary TaxonomyN
Taxonomy Code152WX0102X
TaxonomyOccupational Vision Optometrist
License Number0618001521
License Number StateVA

VIII. Authorized Official

Name: DR. BRENT L SEGELEON
Title or Position: OWNER
Credential: OD
Phone: 757-903-2633