1386866762 NPI number — TUNNEL ROAD OPTOMETRY GROUP

Table of content: (NPI 1386866762)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386866762 NPI number — TUNNEL ROAD OPTOMETRY GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TUNNEL ROAD OPTOMETRY GROUP
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:
ADVANCED EYE CARE
Provider Other Organization Name Type Code:
3
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:
1386866762
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/03/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3316 SILAS CREEK PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINSTON SALEM
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27103-3011
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-765-5350
Provider Business Mailing Address Fax Number:
336-765-0769

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3702 W GATE CITY BLVD
Provider Second Line Business Practice Location Address:
ADVANCED EYE CARE
Provider Business Practice Location Address City Name:
GREENSBORO
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27407-4628
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-854-2020
Provider Business Practice Location Address Fax Number:
336-852-9472
Provider Enumeration Date:
05/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DAVIS
Authorized Official First Name:
ROGER
Authorized Official Middle Name:
G
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
336-765-5350

Provider Taxonomy Codes

  • Taxonomy code: 152WC0802X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5916691 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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