1225155229 NPI number — PAUL LALLANDE, OD, PC, DOCTOR OF OPTOMETRY

Table of content: (NPI 1225155229)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225155229 NPI number — PAUL LALLANDE, OD, PC, DOCTOR OF OPTOMETRY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PAUL LALLANDE, OD, PC, DOCTOR OF OPTOMETRY
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:
1225155229
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/16/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
125 SUFFOLK AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RICHLANDS
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24641-2434
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
276-963-0808
Provider Business Mailing Address Fax Number:
276-963-7538

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
125 SUFFOLK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RICHLANDS
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24641-2434
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
276-963-0808
Provider Business Practice Location Address Fax Number:
276-963-7538
Provider Enumeration Date:
03/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LALLANDE
Authorized Official First Name:
MICHELLE
Authorized Official Middle Name:
CLERC
Authorized Official Title or Position:
SECRETARY-TREASURER
Authorized Official Telephone Number:
276-963-0808

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  0618000220 , 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: 009203567 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 021335 . This is a "ANTHEM BLUE CROSS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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