Healthcare Provider Details

I. General information

NPI: 1831503655
Provider Name (Legal Business Name): GHASSAN Y. DAGHER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2014
Last Update Date: 06/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 6TH AVE SUITE 110
MONTGOMERY WV
25136-2116
US

IV. Provider business mailing address

PO BOX 180
MONTGOMERY WV
25136-0180
US

V. Phone/Fax

Practice location:
  • Phone: 304-442-8076
  • Fax: 304-442-1348
Mailing address:
  • Phone: 304-442-8076
  • Fax: 304-442-1348

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number12037
License Number StateWV

VIII. Authorized Official

Name: DR. GHASSAN Y. DAGHER
Title or Position: OWNER
Credential:
Phone: 304-442-8076