1891726691 NPI number — PR EYECARE CONSULTING GROUP OD PA

Table of content: (NPI 1891726691)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891726691 NPI number — PR EYECARE CONSULTING GROUP OD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PR EYECARE CONSULTING GROUP 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:
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:
1891726691
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/25/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12910 SHELBYVILLE RD STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40243-2404
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-244-2441
Provider Business Mailing Address Fax Number:
502-996-8282

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1040 RANDOLPH STR
Provider Second Line Business Practice Location Address:
STE 14-15
Provider Business Practice Location Address City Name:
THOMASVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27360
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-472-8700
Provider Business Practice Location Address Fax Number:
336-472-8740
Provider Enumeration Date:
07/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ROGASKI
Authorized Official First Name:
PETER
Authorized Official Middle Name:
MICHAEL
Authorized Official Title or Position:
PRESIDENT OWNER
Authorized Official Telephone Number:
336-472-8700

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 89011UP , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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