Healthcare Provider Details

I. General information

NPI: 1912012527
Provider Name (Legal Business Name): MEDICAL OPTICAL LAB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 02/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 S CAMERON ST
WINCHESTER VA
22601-4063
US

IV. Provider business mailing address

302 S CAMERON ST
WINCHESTER VA
22601-4603
US

V. Phone/Fax

Practice location:
  • Phone: 540-667-7482
  • Fax: 540-667-8765
Mailing address:
  • Phone: 540-667-7482
  • Fax: 540-667-8765

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: MR. DIANA G DAUGHERTY
Title or Position: OFFICE MANAGER
Credential: OFFICE MANAGER
Phone: 540-667-7482