1972724201 NPI number — ACADEMY EYE CENTER OPTOMETRY, PA

Table of content: (NPI 1972724201)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972724201 NPI number — ACADEMY EYE CENTER OPTOMETRY, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ACADEMY EYE CENTER OPTOMETRY, 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:
1972724201
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/25/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
213 W NAOMI ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RANDLEMAN
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27317-1733
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-495-3019
Provider Business Mailing Address Fax Number:
336-495-5703

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1040 RANDOLPH ST
Provider Second Line Business Practice Location Address:
SUITE 32
Provider Business Practice Location Address City Name:
THOMASVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27360-6383
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-475-0151
Provider Business Practice Location Address Fax Number:
336-472-6831
Provider Enumeration Date:
05/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MITCHELL
Authorized Official First Name:
JENNIE
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE ADMINISTRATOR
Authorized Official Telephone Number:
336-905-9745

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  1464 , 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: 5901580 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0853510001 . This is a "CIGNA GOVERNMENT SERVICES MEDICARE PART B DME" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 011KT . This is a "BCBS GROUP-T" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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