Healthcare Provider Details

I. General information

NPI: 1104889971
Provider Name (Legal Business Name): FAIRMONT EYE CARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2006
Last Update Date: 12/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

709 MORGANTOWN AVE
FAIRMONT WV
26554
US

IV. Provider business mailing address

709 MORGANTOWN AVE
FAIRMONT WV
26554-4331
US

V. Phone/Fax

Practice location:
  • Phone: 304-366-4721
  • Fax: 304-366-4847
Mailing address:
  • Phone: 304-366-4721
  • Fax: 304-366-4847

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. PHILIP MARC WILMOTH
Title or Position: PRESIDENT DOCTOR
Credential: OD
Phone: 304-366-4721