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General NPI Number Information
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NPI Number | 1245599315
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Entity Type | Organization
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Legal Business Name | WEST VIRGINIA OPTOMETRIC GROUP INC
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Dates
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Enumeration Date | 05/10/2012
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Last Update Date | 05/10/2012
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Provider Practice Location Address
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Address Line | 1476 LAWRENCE ST
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City | FAIRMONT
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State | WV
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Zip | 26554-2355
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Country | US
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Telephone | 304-444-5573
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Fax |
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Provider Business Mailing Address
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Address Line | 1476 LAWRENCE ST
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City | FAIRMONT
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State | WV
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Zip | 26554-2355
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Country | US
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Telephone | 304-444-5573
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Fax |
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Authorized Official
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Title or Position | PRESIDENT/CEO
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Name | DR. KELLI MARIE MCCARTNEY
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Credential | O.D.
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Telephone | 304-444-5573
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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 | 1077-OD
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License Number State | WV
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