1295979672 NPI number — VISTAR EYE CENTER

Table of content: (NPI 1295979672)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295979672 NPI number — VISTAR EYE CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VISTAR EYE CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295979672
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/05/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1789
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROANOKE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24008-1789
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-855-5139
Provider Business Mailing Address Fax Number:
540-342-4373

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3320 FRANKLIN RD SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROANOKE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24014-1310
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-855-5139
Provider Business Practice Location Address Fax Number:
540-342-4373
Provider Enumeration Date:
04/29/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PIERCE
Authorized Official First Name:
HERBURT
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
540-855-3554

Provider Taxonomy Codes

  • Taxonomy code: 332H00000X , with the licence number:  105614 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)