Healthcare Provider Details

I. General information

NPI: 1992269047
Provider Name (Legal Business Name): REGIONAL EYE ASSOCIATES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2019
Last Update Date: 01/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1405 CHANDELL ST
KEYSER WV
26726-2012
US

IV. Provider business mailing address

1255 PINEVIEW DR. WHITE BIRCH TOWER 1
MORGANTOWN WV
26505-2738
US

V. Phone/Fax

Practice location:
  • Phone: 304-598-3301
  • Fax: 304-225-0516
Mailing address:
  • Phone: 304-598-3301
  • Fax: 304-225-4289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: EDGAR C GAMPONIA
Title or Position: AUTHORIZED REP
Credential:
Phone: 304-598-3301