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123 West Wagner, Ellenboro, WV 26346 | |
(304) 869-3028 | |
Not Available |
Full Name | |
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Type | Facility |
Speciality | Optometrist |
Location | 123 West Wagner, Ellenboro, West Virginia |
Accepts Medicare Assignments | Medicare enrolled and accepts medicare insurance. Providers at this facility may prescribe medicare part D drugs. |
Identifier | Type | State | Issuer |
---|---|---|---|
1134316086 | NPI | - | NPPES |
410044882 | Other | WV | RAILROAD MEDICARE |
001711137 | Other | WV | BCBS |
Taxonomy | Type | License (State) | Status |
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152W00000X | Optometrist | 951-OD (West Virginia) | Primary |
332H00000X | Eyewear Supplier | WV 951-OD (West Virginia) | Secondary |
Provider Name | Malinda Lucky Flores |
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Provider Type | Practitioner - Optometry |
Provider Identifiers | NPI Number: 1154370492 PECOS PAC ID: 3779665237 Enrollment ID: I20080123000659 |
Mailing Address | Practice Location Address |
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37 Alexander Dr, Williamstown, WV 26187-8302 Ph: (304) 375-4748 | 123 West Wagner, Ellenboro, WV 26346 Ph: (304) 869-3028 |