1285732453 NPI number — SHELBY EYE CENTERS, P.A.

Table of content: (NPI 1285732453)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285732453 NPI number — SHELBY EYE CENTERS, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHELBY EYE CENTERS, P.A.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SHELBY EYE CENTERS, P.A.
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1285732453
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/13/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1170 WYKE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHELBY
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28150-4259
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-482-6767
Provider Business Mailing Address Fax Number:
704-600-6232

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1170 WYKE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHELBY
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28150-4259
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-482-6767
Provider Business Practice Location Address Fax Number:
704-600-6232
Provider Enumeration Date:
09/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CLINE
Authorized Official First Name:
NANCY
Authorized Official Middle Name:
ELLEN
Authorized Official Title or Position:
PHYSICIAN / VICE PRESIDENT
Authorized Official Telephone Number:
704-482-6767

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  200001408204 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: CC4125 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: D12822 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7204125 . This is a "CIGNA HEALTHCARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: GP3976 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0267J . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 890267J , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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