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General NPI Number Information
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NPI Number | 1700829553
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Entity Type | Organization
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Legal Business Name | COUNTRYSIDE OPTICAL
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Dates
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Enumeration Date | 06/13/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 20 PIDGEON HILL DR SUITE 107
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City | STERLING
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State | VA
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Zip | 20165-6154
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Country | US
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Telephone | 703-444-8500
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Fax | 703-406-3801
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Provider Business Mailing Address
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Address Line | 20 PIDGEON HILL DR SUITE 107
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City | STERLING
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State | VA
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Zip | 20165-6154
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Country | US
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Telephone | 703-444-8500
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Fax | 703-406-3801
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. FRANCISCO ALTAMIRANO
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Credential | DO
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Telephone | 703-444-8500
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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 | 1101-001527
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License Number State | VA
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