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General NPI Number Information
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NPI Number | 1780779835
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Entity Type | Organization
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Legal Business Name | RANDOLPH COUNTY EYE CARE CENTER PC
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Dates
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Enumeration Date | 10/04/2006
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Last Update Date | 04/02/2008
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Provider Practice Location Address
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Address Line | RT 250/219 CHENOWETH CREEK RD
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City | ELKINS
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State | WV
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Zip | 26241
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Country | US
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Telephone | 304-636-3887
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Fax | 304-636-0538
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Provider Business Mailing Address
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Address Line | PO BOX 1489
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City | ELKINS
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State | WV
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Zip | 26241
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Country | US
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Telephone | 304-636-3887
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Fax | 304-636-0538
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Authorized Official
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Title or Position | PRESIDENT OPTOMETRIST
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Name | JENNA LOUISE GONGOLA
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Credential | OD
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Telephone | 304-636-3887
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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 | WV93800
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License Number State | WV
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