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General NPI Number Information
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NPI Number | 1982951497
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Entity Type | Organization
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Legal Business Name | OPTICAL 101, LLC
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Dates
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Enumeration Date | 08/14/2012
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Last Update Date | 08/14/2012
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Provider Practice Location Address
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Address Line | 499 HIGH ST
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City | MORGANTOWN
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State | WV
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Zip | 26505-5516
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Country | US
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Telephone | 304-296-2540
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Fax | 304-296-2542
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Provider Business Mailing Address
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Address Line | 499 HIGH ST
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City | MORGANTOWN
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State | WV
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Zip | 26505-5516
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Country | US
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Telephone | 304-296-2540
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Fax | 304-296-2542
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Authorized Official
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Title or Position | OPTOMETRIST / MANAGING PARTNER
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Name | DR. THOMAS A. BRUGNOLI
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Credential | O.D.
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Telephone | 304-296-2540
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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 | 1086-OD
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License Number State | WV
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