Healthcare Provider Details

I. General information

NPI: 1700094976
Provider Name (Legal Business Name): MAXWELL EYECARE CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 GOFF MOUNTAIN RD SUITE 12
CROSS LANES WV
25313-1419
US

IV. Provider business mailing address

130 GOFF MOUNTAIN RD SUITE 12
CROSS LANES WV
25313-1419
US

V. Phone/Fax

Practice location:
  • Phone: 304-776-5594
  • Fax: 304-776-3521
Mailing address:
  • Phone: 304-776-5594
  • Fax: 304-776-3521

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number866D
License Number StateWV

VIII. Authorized Official

Name: DR. HILDA J MAXWELL
Title or Position: PRESIDENT, OWNER, OD
Credential: OD
Phone: 304-776-5594