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General NPI Number Information
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NPI Number | 1861651507
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Entity Type | Organization
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Legal Business Name | SOUTHWEST VIRGINIA EYE CENTER, PLLC
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Dates
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Enumeration Date | 06/06/2008
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Last Update Date | 06/06/2008
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Provider Practice Location Address
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Address Line | 3090 ELECTRIC RD FSUITE B
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City | ROANOKE
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State | VA
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Zip | 24018-3503
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Country | US
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Telephone | 540-772-3978
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Fax | 540-400-0001
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Provider Business Mailing Address
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Address Line | 3090 ELECTRIC RD FSUITE B
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City | ROANOKE
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State | VA
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Zip | 24018-3503
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Country | US
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Telephone | 540-772-3978
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Fax | 540-400-0001
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Authorized Official
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Title or Position | OWNER
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Name | DR. JONATHAN STANWOOD TILL
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Credential | MD
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Telephone | 540-772-3978
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number | 0101040106
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License Number State | VA
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