Provider Demographics
NPI:1720154974
Name:MARY LEE PEMBERTON, OD PC
Entity type:Organization
Organization Name:MARY LEE PEMBERTON, OD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:PEMBERTON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:540-946-8727
Mailing Address - Street 1:2522 JEFFERSON HWY
Mailing Address - Street 2:SUITE 106
Mailing Address - City:WAYNESBORO
Mailing Address - State:VA
Mailing Address - Zip Code:22980-8503
Mailing Address - Country:US
Mailing Address - Phone:540-946-8727
Mailing Address - Fax:540-949-5526
Practice Address - Street 1:2522 JEFFERSON HWY
Practice Address - Street 2:SUITE 106
Practice Address - City:WAYNESBORO
Practice Address - State:VA
Practice Address - Zip Code:22980-8503
Practice Address - Country:US
Practice Address - Phone:540-946-8727
Practice Address - Fax:540-949-5526
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2009-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000738152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VACO8657Medicare ID - Type UnspecifiedGROUP NUMBER
VA6071520001Medicare NSC