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General NPI Number Information
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NPI Number | 1285885814
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Entity Type | Organization
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Legal Business Name | DR. EDDIE PRENDERGAST OD
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Dates
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Enumeration Date | 10/01/2008
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Last Update Date | 11/07/2008
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Provider Practice Location Address
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Address Line | 651 WATER ST
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City | SUMMERSVILLE
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State | WV
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Zip | 26651-1454
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Country | US
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Telephone | 304-872-5678
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Fax | 307-872-5697
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Provider Business Mailing Address
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Address Line | 651 WATER ST
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City | SUMMERSVILLE
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State | WV
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Zip | 26651-1454
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Country | US
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Telephone | 304-872-5678
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Fax | 307-872-5697
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Authorized Official
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Title or Position | OWNER
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Name | DR. EDDIE LEO PRENDERGAST JR.
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Credential | OD
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Telephone | 304-872-5678
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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 | 666D
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License Number State | WV
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