| Name | Value |
|---|---|
| PROVIDER TYPE | Eye and Vision Services |
| CLASSIFICATION | Optometrist |
| AREA OF SPECIALIZATION | Contact Lens |
| STATUS | Inactive |
| DATE INACTIVATED | 2018-04-02 00:00:00 |
| VA CODE | V060801 |
| X12 CODE | 152WC0800N |
| MASTER ENTRY FOR VUID | YES |
| VUID | 5252594 |
| EFFECTIVE DATE/TIME |
|