Healthcare Provider Details

I. General information

NPI: 1598820680
Provider Name (Legal Business Name): WYTHE EYE ASSOCIATES AMANDA BREWER-SMITH OD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 01/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 W RIDGE RD
WYTHEVILLE VA
24382-1188
US

IV. Provider business mailing address

PO BOX 914
WYTHEVILLE VA
24382-0914
US

V. Phone/Fax

Practice location:
  • Phone: 276-223-0033
  • Fax: 276-223-0327
Mailing address:
  • Phone: 276-223-0033
  • Fax: 276-223-0327

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618000743
License Number StateVA

VIII. Authorized Official

Name: AMANDA BREWER LORD
Title or Position: OPTOMETRIST
Credential: OD
Phone: 276-223-0033