1700839305 NPI number — METROLINA EYE ASSOCIATES, PLLC

Table of content: (NPI 1700839305)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700839305 NPI number — METROLINA EYE ASSOCIATES, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
METROLINA EYE ASSOCIATES, PLLC
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:
1700839305
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/26/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
630 COMFORT LANE
Provider Second Line Business Mailing Address:
SUITE E
Provider Business Mailing Address City Name:
MONROE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28112-6493
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-289-5455
Provider Business Mailing Address Fax Number:
704-291-2207

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
630 COMFORT LANE
Provider Second Line Business Practice Location Address:
SUITE E
Provider Business Practice Location Address City Name:
MONROE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28112-6493
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-289-5455
Provider Business Practice Location Address Fax Number:
704-291-2207
Provider Enumeration Date:
05/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TAVARES
Authorized Official First Name:
NICOLAS
Authorized Official Middle Name:
M
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
704-234-1934

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 89016P7 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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