Provider Demographics
NPI:1427071141
Name:MANN, BECKY C (OD)
Entity type:Individual
Prefix:DR
First Name:BECKY
Middle Name:C
Last Name:MANN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CHRISTIANSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24073-2941
Mailing Address - Country:US
Mailing Address - Phone:540-381-2020
Mailing Address - Fax:540-382-2660
Practice Address - Street 1:29 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CHRISTIANSBURG
Practice Address - State:VA
Practice Address - Zip Code:24073-2941
Practice Address - Country:US
Practice Address - Phone:540-381-2020
Practice Address - Fax:540-382-2660
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2018-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000181152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4721480001OtherADMINISTAR FEDERAL
VA410012808OtherPALMETTO GBA
VA466478OtherANTHEM
VA9202552Medicaid
VAT21974Medicare UPIN
VA9202552Medicaid
VA4721480001Medicare NSC
VA00X700E02Medicare PIN