Healthcare Provider Details

I. General information

NPI: 1861629917
Provider Name (Legal Business Name): GREENBRIER PHYSICIANS, INC. OPTICAL SHOP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2009
Last Update Date: 06/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MAPLEWOOD AVE
RONCEVERTE WV
24970-1334
US

IV. Provider business mailing address

200 MAPLEWOOD AVE
RONCEVERTE WV
24970-1334
US

V. Phone/Fax

Practice location:
  • Phone: 304-647-1147
  • Fax: 304-647-3006
Mailing address:
  • Phone: 304-647-1147
  • Fax: 304-647-3006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code156F00000X
TaxonomyTechnician/Technologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code156FC0800X
TaxonomyContact Lens Technician/Technologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code156FC0801X
TaxonomyContact Lens Fitter
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code156FX1101X
TaxonomyOphthalmic Assistant
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code156FX1100X
TaxonomyOphthalmic Technician/Technologist
License Number
License Number State

VIII. Authorized Official

Name: MR. JOHN D. TROUT
Title or Position: CLINIC ADMINISTRATOR
Credential:
Phone: 304-647-1140