Healthcare Provider Details

I. General information

NPI: 1437493319
Provider Name (Legal Business Name): MOUNTAIN STATE EYE ASSOCIATES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2012
Last Update Date: 12/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1306 KANAWHA BLVD EAST
CHARLESTON WV
25301-3001
US

IV. Provider business mailing address

PO BOX 5308
CHARLESTON WV
25361-0308
US

V. Phone/Fax

Practice location:
  • Phone: 304-353-0304
  • Fax: 304-353-0218
Mailing address:
  • Phone: 304-353-0304
  • Fax: 304-353-0218

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberWV8200D
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberWV20725
License Number StateWV
# 3
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberWV21067
License Number StateWV

VIII. Authorized Official

Name: MRS. ANNE ELIZABETH BOUNDS
Title or Position: OFFICE MANAGER
Credential:
Phone: 304-353-0222