1770815722 NPI number — KERNERSVILLE EYE ASSOCIATES, O.D., P.A.

Table of content: (NPI 1770815722)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770815722 NPI number — KERNERSVILLE EYE ASSOCIATES, O.D., P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KERNERSVILLE EYE ASSOCIATES, O.D., 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:
1770815722
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/03/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1635 NC HIGHWAY 66 S STE 155
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KERNERSVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27284-3855
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-992-0010
Provider Business Mailing Address Fax Number:
336-245-4636

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1030 S MAIN ST
Provider Second Line Business Practice Location Address:
SUITE Q
Provider Business Practice Location Address City Name:
KERNERSVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27284-7490
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-992-0010
Provider Business Practice Location Address Fax Number:
336-245-4636
Provider Enumeration Date:
02/02/2010

Additional Information

Authorized Official

Authorized Official Last Name:
SUBRAMANIAN
Authorized Official First Name:
ARUN
Authorized Official Middle Name:
T
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
336-992-0010

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  2006 , 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: 5905630 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7866788 . This is a "AETNA US HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 807938 . This is a "PARTNERS NATIONAL HEALTH PLAN" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 093U1 . This is a "BCBS OF NC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2630870 . This is a "UNITED HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00450033 . This is a "PALMETTO GBA RAILROAD MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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