1255486882 NPI number — SPECTRUM OPTICAL PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255486882 NPI number — SPECTRUM OPTICAL PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPECTRUM OPTICAL PLLC
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:
6
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:
1255486882
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/12/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1257 PINEVIEW DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MORGANTOWN
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26505-2713
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-599-7034
Provider Business Mailing Address Fax Number:
304-599-5483

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1257 PINEVIEW DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MORGANTOWN
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26505-2713
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-599-7034
Provider Business Practice Location Address Fax Number:
304-599-5483
Provider Enumeration Date:
01/24/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GOELLNER
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
HENRY
Authorized Official Title or Position:
MANAGING PARTNER
Authorized Official Telephone Number:
304-599-7034

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3810002839 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".




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