1386861326 NPI number — CHATHAM OPTOMETRIC OD PA

Table of content: (NPI 1386861326)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386861326 NPI number — CHATHAM OPTOMETRIC OD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHATHAM OPTOMETRIC OD 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:
6
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:
1386861326
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/25/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11312 US HIGHWAY 15-501 NORTH
Provider Second Line Business Mailing Address:
STE 304
Provider Business Mailing Address City Name:
CHAPEL HILL
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27517-6376
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-933-6767
Provider Business Mailing Address Fax Number:
919-933-6732

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11312 US HIGHWAY 15-501 NORTH
Provider Second Line Business Practice Location Address:
STE 304
Provider Business Practice Location Address City Name:
CHAPEL HILL
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27517-6376
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-933-6767
Provider Business Practice Location Address Fax Number:
919-933-6732
Provider Enumeration Date:
04/19/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MARSHALL
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
BRYAN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
919-933-6767

Provider Taxonomy Codes

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

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

  • Identifier: 790136L , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8909104 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4480650001 . This is a "MEDICARE PTAN" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 152W00000X . This is a "TAXONOMY NUMBER" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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