Healthcare Provider Details

I. General information

NPI: 1831398510
Provider Name (Legal Business Name): MICHAEL R. LOOPER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2007
Last Update Date: 09/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 BUCKHANNON CROSSROADS
BUCKHANNON WV
26201
US

IV. Provider business mailing address

100 BUCKHANNON CROSSROADS
BUCKHANNON WV
26201
US

V. Phone/Fax

Practice location:
  • Phone: 304-472-7703
  • Fax: 304-472-8808
Mailing address:
  • Phone: 304-472-7703
  • Fax: 304-472-8808

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number727D
License Number StateWV

VIII. Authorized Official

Name: GWENDOLYN WEESE
Title or Position: OFFICE MANAGER
Credential:
Phone: 304-472-7703