Basic Information
| Provider Information | |||||||||
| NPI: | 1336412071 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EYE CARE ASSOCIATES OD PA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | EYE CARE ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7100 SIX FORKS RD | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276156156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198470187 | ||||||||
| FaxNumber: | 9196762231 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 CAPCOM AVE | ||||||||
| Address2: | |||||||||
| City: | WAKE FOREST | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275876531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9195561909 | ||||||||
| FaxNumber: | 9195566765 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2012 | ||||||||
| LastUpdateDate: | 02/11/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BOLICK | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/CEO | ||||||||
| AuthorizedOfficialTelephone: | 9198470187 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | OD | ||||||||
| NPICertificationDate: | |||||||||
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 | 025YX | 01 | NC | BCBS NC | OTHER | 5920462 | 05 | NC | MEDICAID |