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General NPI Number Information
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NPI Number | 1609312537
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Entity Type | Organization
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Legal Business Name | PROVISION LLC
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Dates
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Enumeration Date | 01/17/2017
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Last Update Date | 10/19/2017
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Provider Practice Location Address
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Address Line | 306 SOUTHRIDGE BLVD
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City | SOUTH CHARLESTON
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State | WV
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Zip | 25309-9434
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Country | US
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Telephone | 304-744-4017
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Fax | 304-744-4018
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Provider Business Mailing Address
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Address Line | 306 SOUTHRIDGE BLVD
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City | SOUTH CHARLESTON
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State | WV
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Zip | 25309-9434
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Country | US
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Telephone | 304-744-4017
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Fax | 304-744-4018
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Authorized Official
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Title or Position | OWNER
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Name | DAVID BEECHER
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Credential | OD
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Telephone | 304-744-4017
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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 | 2030-IOD
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License Number State | WV
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