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General NPI Number Information
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NPI Number | 1013018423
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Entity Type | Organization
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Legal Business Name | DR. BLAKE MITNICK, OPTOMETRIST, PLC
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Dates
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Enumeration Date | 09/26/2006
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Last Update Date | 11/05/2010
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Provider Practice Location Address
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Address Line | 211 W MAIN ST
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City | FLOYD
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State | VA
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Zip | 24091-3190
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Country | US
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Telephone | 540-745-8733
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Fax |
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Provider Business Mailing Address
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Address Line | 211 W MAIN ST
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City | FLOYD
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State | VA
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Zip | 24091-3190
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Country | US
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Telephone | 540-745-8733
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Fax |
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Authorized Official
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Title or Position | OPTOMETRIST
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Name | DR. BLAKE MITNICK
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Credential | O.D.
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Telephone | 540-745-8733
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 0618000582
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License Number State | VA
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