Provider Demographics
NPI:1063704435
Name:EYE CARE ON THE RIDGE LLC
Entity type:Organization
Organization Name:EYE CARE ON THE RIDGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAD
Authorized Official - Middle Name:L
Authorized Official - Last Name:WHEATLEY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:276-728-9323
Mailing Address - Street 1:843 W STUART DR
Mailing Address - Street 2:
Mailing Address - City:HILLSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24343-1577
Mailing Address - Country:US
Mailing Address - Phone:276-728-9323
Mailing Address - Fax:
Practice Address - Street 1:843 W STUART DR
Practice Address - Street 2:
Practice Address - City:HILLSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24343-1577
Practice Address - Country:US
Practice Address - Phone:276-728-9323
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-04
Last Update Date:2011-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618001276152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1821077686OtherWHEATLEY NPI