1396934709 NPI number — EYE CARE CENTER OF VIRGINIA PC

Table of content: (NPI 1396934709)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396934709 NPI number — EYE CARE CENTER OF VIRGINIA PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EYE CARE CENTER OF VIRGINIA PC
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:
GARTH STEVENS JR MD
Provider Other Organization Name Type Code:
5
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:
1396934709
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/18/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2924 EMERYWOOD PKWY STE 103
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HENRICO
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23294-3746
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
804-330-9303
Provider Business Mailing Address Fax Number:
804-330-9302

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2924 EMERYWOOD PKWY STE 103
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HENRICO
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23294-3746
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-330-9303
Provider Business Practice Location Address Fax Number:
804-330-9302
Provider Enumeration Date:
10/22/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
STEVENS
Authorized Official First Name:
GARTH
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
804-330-9303

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  0101041201 , 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)

  • Identifier: 006308287 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: DA5002 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".