1952419962 NPI number — HAYWOOD OPTOMETRIC CARE PA

Table of content: (NPI 1952419962)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952419962 NPI number — HAYWOOD OPTOMETRIC CARE PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HAYWOOD OPTOMETRIC CARE PA
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:
1952419962
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/21/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
29 N MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAYNESVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28786-3886
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
828-456-8361
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
29 N MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAYNESVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28786-3886
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
828-456-8361
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/29/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ROBERSON
Authorized Official First Name:
LEROY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
828-456-7142

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  0928 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 152WC0802X , with the licence number: 0928 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 22-70673 . This is a "UHC #" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 5856910001 . This is a "DMERC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 0262B . This is a "BC/BS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 1952419962 . This is a "NPI" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 5904769 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".