Provider Demographics
NPI:1962540534
Name:WAL-DAV INCORPORATED
Entity type:Organization
Organization Name:WAL-DAV INCORPORATED
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:G
Authorized Official - Last Name:WALLACE-DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:757-827-6612
Mailing Address - Street 1:1134 BIG BETHEL RD
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-1906
Mailing Address - Country:US
Mailing Address - Phone:757-827-6612
Mailing Address - Fax:757-827-6296
Practice Address - Street 1:1134 BIG BETHEL RD
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-1906
Practice Address - Country:US
Practice Address - Phone:757-827-6612
Practice Address - Fax:757-827-6296
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-03
Last Update Date:2011-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000303152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA009232583Medicaid
VA009232583Medicaid
VAA349Medicare PIN