1114108891 NPI number — BRIANA J. SHELTON, OD, PA D/B/A PROFESSIONAL VISION CENTERS

Table of content: (NPI 1114108891)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114108891 NPI number — BRIANA J. SHELTON, OD, PA D/B/A PROFESSIONAL VISION CENTERS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRIANA J. SHELTON, OD, PA D/B/A PROFESSIONAL VISION CENTERS
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:
PROFESSIONAL VISION CENTER
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:
1114108891
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
364 US 70 W
Provider Second Line Business Mailing Address:
SUITE 4
Provider Business Mailing Address City Name:
MARION
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28752-6243
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
828-652-1020
Provider Business Mailing Address Fax Number:
828-652-8302

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
364 US 70 W
Provider Second Line Business Practice Location Address:
SUITE 4
Provider Business Practice Location Address City Name:
MARION
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28752-6243
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
828-652-1020
Provider Business Practice Location Address Fax Number:
828-652-8302
Provider Enumeration Date:
11/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SHELTON
Authorized Official First Name:
BRIANA
Authorized Official Middle Name:
JOHNSON
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
828-652-1020

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  1837 , 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: 1837 . This is a "TRICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2335795 . This is a "MEDICARE GROUP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 89093NG , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00105772 . This is a "MEDICARE RR" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 093NG . This is a "BCBS NC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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