Provider Demographics
NPI:1336197540
Name:DVC OF VIRGINIA PC
Entity type:Organization
Organization Name:DVC OF VIRGINIA PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:M
Authorized Official - Last Name:BURGESS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-442-0802
Mailing Address - Street 1:540 LEW DEWITT BOULEVARD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:WAYNESBORO
Mailing Address - State:VA
Mailing Address - Zip Code:22980
Mailing Address - Country:US
Mailing Address - Phone:540-943-7486
Mailing Address - Fax:540-942-2251
Practice Address - Street 1:540 LEW DEWITT BOULEVARD
Practice Address - Street 2:SUITE 5
Practice Address - City:WAYNESBORO
Practice Address - State:VA
Practice Address - Zip Code:22980
Practice Address - Country:US
Practice Address - Phone:540-943-7486
Practice Address - Fax:540-942-2251
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-04
Last Update Date:2009-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAP00753364OtherNOWAK RRMCR INDIVIDUAL NUMBER
VA010257468Medicaid
VA189926OtherANTHEM BCBS
VADG0209OtherWAY GROUP RRMCR NUMBER
VA010257468Medicaid
VAC09838Medicare PIN