Provider Demographics
NPI:1538335401
Name:TASSO BUTLER
Entity type:Organization
Organization Name:TASSO BUTLER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TASSO
Authorized Official - Middle Name:S
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:JR
Authorized Official - Credentials:OD
Authorized Official - Phone:304-645-6408
Mailing Address - Street 1:US RT 219
Mailing Address - Street 2:GREENBRIER VALLEY MALL
Mailing Address - City:LEWISBURG
Mailing Address - State:WV
Mailing Address - Zip Code:24901
Mailing Address - Country:US
Mailing Address - Phone:304-645-6408
Mailing Address - Fax:304-647-3962
Practice Address - Street 1:US RT 219
Practice Address - Street 2:GREENBRIER VALLEY MALL
Practice Address - City:LEWISBURG
Practice Address - State:WV
Practice Address - Zip Code:24901
Practice Address - Country:US
Practice Address - Phone:304-645-6408
Practice Address - Fax:304-647-3962
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TASSO S. BUTLER, JR. O.D.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-01
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV658-OD332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0762670001Medicare NSC