=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255486882
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPECTRUM OPTICAL PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/24/2007
-----------------------------------------------------
Last Update Date | 08/12/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1257 PINEVIEW DR
-----------------------------------------------------
City | MORGANTOWN
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26505-2713
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-599-7034
-----------------------------------------------------
Fax | 304-599-5483
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1257 PINEVIEW DR
-----------------------------------------------------
City | MORGANTOWN
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26505-2713
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-599-7034
-----------------------------------------------------
Fax | 304-599-5483
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING PARTNER
-----------------------------------------------------
Name | RICHARD HENRY GOELLNER
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 304-599-7034
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------