Basic Information
| Provider Information | |||||||||
| NPI: | 1255365573 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PIEDMONT OPHTHALMOLOGY CLINIC, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DOMINION EYE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 MEMORIAL DR | ||||||||
| Address2: | SUITE A | ||||||||
| City: | DANVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245411680 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4347993232 | ||||||||
| FaxNumber: | 4347925125 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 MEMORIAL DR | ||||||||
| Address2: | SUITE A | ||||||||
| City: | DANVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245411680 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4347993232 | ||||||||
| FaxNumber: | 4347925125 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 12/07/2007 | ||||||||
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| AuthorizedOfficialLastName: | GAMMON | ||||||||
| AuthorizedOfficialFirstName: | MELISSA | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4347993232 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | COE | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 0618000031 | VA | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.