1972561306 NPI number — TIMOTHY JAMES HENNIE O.D.

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972561306 NPI number — TIMOTHY JAMES HENNIE O.D.

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

HENNIE

Provider First Name:

TIMOTHY

Provider Middle Name:

JAMES

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

O.D.

Provider Gender Code:

M

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:

1972561306

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

02/27/2013

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

1910 JAKE ALEXANDER BLVD W

Provider Second Line Business Mailing Address:

SUITE 101

Provider Business Mailing Address City Name:

SALISBURY

Provider Business Mailing Address State Name:

NC

Provider Business Mailing Address Postal Code:

28147-1162

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

704-633-2581

Provider Business Mailing Address Fax Number:

704-633-2592

Provider First Line Business Practice Location Address:

1910 JAKE ALEXANDER BLVD W

Provider Second Line Business Practice Location Address:

SUITE 101

Provider Business Practice Location Address City Name:

SALISBURY

Provider Business Practice Location Address State Name:

NC

Provider Business Practice Location Address Postal Code:

28147-1163

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

704-633-2581

Provider Business Practice Location Address Fax Number:

704-633-2592

Provider Enumeration Date:

05/03/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 152W00000X , with the licence number:  1071 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 561430045 . This is a "SUPERIOR VISION PLAN" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
• Identifier: 2200141 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
• Identifier: 51812 . This is a "DAVIS VISION PLAN" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
• Identifier: 8909387 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
• Identifier: 110899 . This is a "EYEMED" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
• Identifier: 09387 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
• Identifier: 10799 . This is a "OPTICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
• Identifier: 48550 . This is a "SPECTERA" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
• Identifier: NC01071 . This is a "VISION BENEFITS OF AMERIC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
• Identifier: 561430045 . This is a "PRIMARY PHYSICIAN CARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
• Identifier: 561430045 . This is a "PARTNERS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".