Basic Information
| Provider Information | |||||||||
| NPI: | 1295916732 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WAKE FOREST FAMILY EYE CARE, O.D., P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 CAPCOM AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | WAKE FOREST | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275876531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9195561909 | ||||||||
| FaxNumber: | 9195566765 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 CAPCOM AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | WAKE FOREST | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275876531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9195561909 | ||||||||
| FaxNumber: | 9195566765 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/26/2007 | ||||||||
| LastUpdateDate: | 07/27/2009 | ||||||||
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| AuthorizedOfficialLastName: | BELL | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
| AuthorizedOfficialMiddleName: | KEVIN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9195561909 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | O.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1145 | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.