Healthcare Provider Details

I. General information

NPI: 1134316086
Provider Name (Legal Business Name): LUCKY EYE CARE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2007
Last Update Date: 05/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 WEST WAGNER
ELLENBORO WV
26346
US

IV. Provider business mailing address

37 ALEXANDER DR
WILLIAMSTOWN WV
26187-8302
US

V. Phone/Fax

Practice location:
  • Phone: 304-869-3028
  • Fax:
Mailing address:
  • Phone: 304-375-4748
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number951-OD
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License NumberWV 951-OD
License Number StateWV

VIII. Authorized Official

Name: DR. MALINDA LUCKY FLORES
Title or Position: OWNER
Credential: O.D.
Phone: 304-375-4748