Healthcare Provider Details

I. General information

NPI: 1225219611
Provider Name (Legal Business Name): DR. T. SHAWN STEPHENS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2007
Last Update Date: 07/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

244 GRAND CENTRAL MALL
VIENNA WV
26101-1105
US

IV. Provider business mailing address

244 GRAND CENTRAL MALL
VIENNA WV
26101-1105
US

V. Phone/Fax

Practice location:
  • Phone: 304-485-1199
  • Fax: 304-428-8102
Mailing address:
  • Phone: 304-485-1199
  • Fax: 304-428-8102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1004-D
License Number StateWV

VIII. Authorized Official

Name: TIMOTHY SHAWN STEPHENS
Title or Position: OWNER
Credential: OD
Phone: 304-485-1199