=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801976097
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GROVE AVE EYE CENTER PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/16/2006
-----------------------------------------------------
Last Update Date | 06/10/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3601 GROVE AVE
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23221-2201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-358-8443
-----------------------------------------------------
Fax | 804-358-1395
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3601 GROVE AVE
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23221-2201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-358-8443
-----------------------------------------------------
Fax | 804-358-1395
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP/OPTOMETRIST
-----------------------------------------------------
Name | DR. GERALD ROBERT NEIDIGH JR.
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 804-353-3937
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------