MEDICARE: REBECCA ST JEAN OD INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	989-OD	WV

General Provider Information

NPI Number	:	1053586008
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REBECCA ST JEAN OD INC

Provider Business Mailing Address
First Line	:	4030 MACCORKLE AVE SW
Second Line	:
City	:	SOUTH CHARLESTON
State	:	WV
Zip	:	25309-1510
Country	:	US
Telephone Number	:	304-766-2220
Fax Number	:	304-766-0824

Provider Business Practice Location Address
First Line	:	4030 MACCORKLE AVE SW
Second Line	:
City	:	SOUTH CHARLESTON
State	:	WV
Zip	:	25309-1510
Country	:	US
Telephone Number	:	304-766-2220
Fax Number	:	304-766-0824

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. REBECCA V ST. JEAN
Credential	:	O.D.
Telephone Number	:	304-766-2220

Provider Enumeration Date	:	04/29/2008
Last Update Date	:	11/05/2012

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