Provider Demographics
NPI:1912350836
Name:RIVER VALLEY EYE ASSOCIATES
Entity type:Organization
Organization Name:RIVER VALLEY EYE ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:ELAINE
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-677-6770
Mailing Address - Street 1:953 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:YADKINVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27055-6765
Mailing Address - Country:US
Mailing Address - Phone:336-677-6770
Mailing Address - Fax:
Practice Address - Street 1:953 S STATE ST
Practice Address - Street 2:
Practice Address - City:YADKINVILLE
Practice Address - State:NC
Practice Address - Zip Code:27055-6765
Practice Address - Country:US
Practice Address - Phone:336-677-6770
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-15
Last Update Date:2016-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2197152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5916137Medicaid
NCNCA749AMedicare UPIN