Provider Demographics
NPI:1487428660
Name:POOVEY, BENJAMIN CARROLL
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:CARROLL
Last Name:POOVEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7373 PEPPERS FERRY BLVD
Mailing Address - Street 2:
Mailing Address - City:FAIRLAWN
Mailing Address - State:VA
Mailing Address - Zip Code:24141-8857
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7373 PEPPERS FERRY BLVD
Practice Address - Street 2:
Practice Address - City:FAIRLAWN
Practice Address - State:VA
Practice Address - Zip Code:24141-8857
Practice Address - Country:US
Practice Address - Phone:540-731-4090
Practice Address - Fax:540-731-4089
Is Sole Proprietor?:No
Enumeration Date:2023-11-08
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1101004468156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician