Basic Information
| Provider Information | |||||||||
| NPI: | 1861629917 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GREENBRIER PHYSICIANS, INC. OPTICAL SHOP | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 200 MAPLEWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | RONCEVERTE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 249701334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046471147 | ||||||||
| FaxNumber: | 3046473006 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 MAPLEWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | RONCEVERTE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 249701334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046471147 | ||||||||
| FaxNumber: | 3046473006 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2009 | ||||||||
| LastUpdateDate: | 06/16/2009 | ||||||||
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| AuthorizedOfficialLastName: | TROUT | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINIC ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3046471140 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GREENBRIER PHYSICIANS, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 156F00000X | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Technician/Technologist | 156FC0800X | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Technician/Technologist | Contact Lens | 156FC0801X | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Technician/Technologist | Contact Lens Fitter | 156FX1101X | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Technician/Technologist | Ophthalmic Assistant | 156FX1100X | Y | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Technician/Technologist | Ophthalmic |
No ID Information.