1437337136 NPI number — OPTOMETRIC EYE SITE PLLC

Table of content: (NPI 1437337136)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437337136 NPI number — OPTOMETRIC EYE SITE PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OPTOMETRIC EYE SITE PLLC
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:
Provider Other Organization Name Type Code:
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:
1437337136
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/05/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 12134
Provider Second Line Business Mailing Address:
OPTOMETRIC EYE SITE PLLC
Provider Business Mailing Address City Name:
DURHAM
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27709-2134
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 N COOPER DR
Provider Second Line Business Practice Location Address:
WAL MART VISION CENTER
Provider Business Practice Location Address City Name:
HENDERSON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27536-4016
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-430-7708
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/05/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
COWARD
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
312-771-7411

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  NC 1947 , 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: 1134166986 . This is a "NPI" identifier . This identifiers is of the category "OTHER".