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General NPI Number Information
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NPI Number | 1740424126
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Entity Type | Organization
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Legal Business Name | VISTAR EYE CENTER
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Dates
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Enumeration Date | 04/29/2009
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Last Update Date | 04/29/2009
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Provider Practice Location Address
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Address Line | 548 BLUE RIDGE AVE
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City | BEDFORD
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State | VA
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Zip | 24523-2604
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Country | US
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Telephone | 540-855-5139
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Fax | 540-342-4373
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Provider Business Mailing Address
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Address Line | PO BOX 1789
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City | ROANOKE
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State | VA
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Zip | 24008-1789
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Country | US
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Telephone | 540-855-5139
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Fax | 540-342-4373
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MRS. KATHY P COWAN
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Credential |
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Telephone | 540-855-5123
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number | 1156
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License Number State | VA
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