Healthcare Provider Details

I. General information

NPI: 1003446444
Provider Name (Legal Business Name): REGIONAL EYE ASSOCIATES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2020
Last Update Date: 01/28/2020
Certification Date: 01/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 MEDICAL PARK DR STE 100
WESTON WV
26452-1678
US

IV. Provider business mailing address

1255 PINEVIEW DR
MORGANTOWN WV
26505-2738
US

V. Phone/Fax

Practice location:
  • Phone: 304-406-6555
  • Fax:
Mailing address:
  • Phone: 304-598-3301
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: EDGAR C GAMPONIA
Title or Position: MANAGING PARTNER
Credential:
Phone: 304-598-3301