Basic Information
| Provider Information | |||||||||
| NPI: | 1477888394 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TOTAL EYE OD, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15189 MONTANUS DRIVE | ||||||||
| Address2: | |||||||||
| City: | CULPEPER | ||||||||
| State: | VA | ||||||||
| PostalCode: | 227011679 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5408258220 | ||||||||
| FaxNumber: | 5408258675 | ||||||||
| Practice Location | |||||||||
| Address1: | 15189 MONTANUS DRIVE | ||||||||
| Address2: | |||||||||
| City: | CULPEPER | ||||||||
| State: | VA | ||||||||
| PostalCode: | 227011679 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5408258220 | ||||||||
| FaxNumber: | 5408258675 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2009 | ||||||||
| LastUpdateDate: | 07/24/2012 | ||||||||
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| AuthorizedOfficialLastName: | CHURCH | ||||||||
| AuthorizedOfficialFirstName: | BRADLEY | ||||||||
| AuthorizedOfficialMiddleName: | W. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5408258220 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | O.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 0618000722 | VA | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.