Basic Information
| Provider Information | |||||||||
| NPI: | 1053650820 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EYE CARE ASSOCIATES OD PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7100 SIX FORKS RD | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276156156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198470187 | ||||||||
| FaxNumber: | 9196762231 | ||||||||
| Practice Location | |||||||||
| Address1: | 173 GRAND HILL PLACE | ||||||||
| Address2: | |||||||||
| City: | HOLLY SPRINGS | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193462062 | ||||||||
| FaxNumber: | 9193462069 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2013 | ||||||||
| LastUpdateDate: | 11/25/2013 | ||||||||
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| AuthorizedOfficialLastName: | BOLICK | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9198470187 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | OD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 027Y1 | 01 | BCBS OF NC | OTHER | 5922296 | 05 | NC | MEDICAID |