Provider Demographics
NPI:1124340559
Name:FAMILY VISION CARE INC
Entity type:Organization
Organization Name:FAMILY VISION CARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:E
Authorized Official - Last Name:PUGH
Authorized Official - Suffix:III
Authorized Official - Credentials:OD
Authorized Official - Phone:303-640-4258
Mailing Address - Street 1:100 FAYETTE TOWN CTR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25840-9539
Mailing Address - Country:US
Mailing Address - Phone:304-574-3557
Mailing Address - Fax:
Practice Address - Street 1:100 FAYETTE TOWN CTR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:WV
Practice Address - Zip Code:25840-9539
Practice Address - Country:US
Practice Address - Phone:304-574-3557
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-26
Last Update Date:2010-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1042-OD152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810016948Medicaid