Provider Demographics
NPI:1649933763
Name:MODERNEYES, PLLC
Entity type:Organization
Organization Name:MODERNEYES, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:M
Authorized Official - Last Name:SUPPA SAMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:304-545-8366
Mailing Address - Street 1:1171 CREEKSTONE RDG
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-9476
Mailing Address - Country:US
Mailing Address - Phone:304-545-8366
Mailing Address - Fax:
Practice Address - Street 1:4202 MACCORKLE AVE SE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-2502
Practice Address - Country:US
Practice Address - Phone:304-925-4761
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MODERNEYES, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-10-15
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3910005909Medicaid