Healthcare Provider Details

I. General information

NPI: 1104199892
Provider Name (Legal Business Name): ELECTRA VISION, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2012
Last Update Date: 08/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 OAK LEE DR SUITE 12B
RANSON WV
25438-4871
US

IV. Provider business mailing address

217 OAK LEE DR SUITE 12B
RANSON WV
25438-4871
US

V. Phone/Fax

Practice location:
  • Phone: 304-724-2025
  • Fax:
Mailing address:
  • Phone: 304-724-2025
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1021-OD
License Number StateWV

VIII. Authorized Official

Name: DR. BARBARA PITTARAS
Title or Position: OWNER
Credential: O.D.
Phone: 304-724-2025