1619366507 NPI number — SOUTH FORK OPTOMETRIC ASSOCIATES, P.A.

Table of content: (NPI 1619366507)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619366507 NPI number — SOUTH FORK OPTOMETRIC ASSOCIATES, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH FORK OPTOMETRIC ASSOCIATES, 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:
1619366507
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/14/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
307 ETHAN LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELMONT
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28012-4116
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9820 CALLABRIDGE CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28216-7669
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-394-3886
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/14/2015

Additional Information

Authorized Official

Authorized Official Last Name:
FAULK
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
704-394-3886

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  2328 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 152W00000X , with the licence number: 2255 , 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: 02917 . This is a "DAVIS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 0938G . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 1741X . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: A16758 . This is a "EYEMED" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 17174 . This is a "AVESIS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: A12474 . This is a "EYEMED" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com