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General NPI Number Information
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NPI Number | 1386373769
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Entity Type | Organization
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Legal Business Name | EYECANDY OF WEST VIRGINIA LLC
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Dates
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Enumeration Date | 06/09/2022
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Last Update Date | 10/26/2022
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Provider Practice Location Address
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Address Line | 808 N EISENHOWER DR
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City | BECKLEY
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State | WV
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Zip | 25801-3129
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Country | US
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Telephone | 681-238-5537
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Fax |
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Provider Business Mailing Address
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Address Line | 808 N EISENHOWER DR
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City | BECKLEY
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State | WV
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Zip | 25801-3129
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Country | US
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Telephone | 681-238-5537
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MR. JAMES DARRELL RUDD
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Credential |
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Telephone | 681-238-5537
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 156FX1800X
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Taxonomy Name | Optician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 332BC3200X
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Taxonomy Name | Customized Equipment (DME)
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number |
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License Number State |
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