Basic Information
| Provider Information | |||||||||
| NPI: | 1366420770 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JICHA EYE CARE AND ASSOCIATES PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3911 FOUNTAIN GROVE DR | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | HIGH POINT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272658032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368892225 | ||||||||
| FaxNumber: | 3368892252 | ||||||||
| Practice Location | |||||||||
| Address1: | 3911 FOUNTAIN GROVE DRIVE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | HIGH POINT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272658332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368892225 | ||||||||
| FaxNumber: | 3368892252 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2006 | ||||||||
| LastUpdateDate: | 07/15/2014 | ||||||||
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| AuthorizedOfficialLastName: | JICHA | ||||||||
| AuthorizedOfficialFirstName: | DIANNA | ||||||||
| AuthorizedOfficialMiddleName: | POPA | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3368892225 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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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 | 89015MC | 05 | NC | MEDICAID |