=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013130939
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | C. RICHARD SNIVELY, JR., O.D.,P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 120 BEULAH RD NE
-----------------------------------------------------
City | VIENNA
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22180-4745
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-938-7633
-----------------------------------------------------
Fax | 703-938-4407
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 120 BEULAH RD NE
-----------------------------------------------------
City | VIENNA
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22180-4745
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-938-7633
-----------------------------------------------------
Fax | 703-938-4407
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. RICHARD SNIVELY
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 703-938-7633
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 0618000132
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------