1104922210 NPI number — VISION PARK OPTOMETRY, P.A.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104922210 NPI number — VISION PARK OPTOMETRY, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VISION PARK OPTOMETRY, 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:
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:
1104922210
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/30/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8311 BANDFORD WAY
Provider Second Line Business Mailing Address:
SUITE 105
Provider Business Mailing Address City Name:
RALEIGH
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27615-2756
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-870-1880
Provider Business Mailing Address Fax Number:
919-847-4509

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8311 BANDFORD WAY
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
RALEIGH
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27615-2756
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-870-1880
Provider Business Practice Location Address Fax Number:
919-847-4509
Provider Enumeration Date:
09/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MOORE
Authorized Official First Name:
ANN
Authorized Official Middle Name:
GROOMER
Authorized Official Title or Position:
OPTOMETRIST/ CORPORATE PRESIDENT
Authorized Official Telephone Number:
919-870-1880

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , 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: 410033568 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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