Basic Information
| Provider Information | |||||||||
| NPI: | 1376582239 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EYECARECENTER OD PA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | OPTOMETRIC EYE CARE CENTER OD PA | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 207261 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753207261 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6362004393 | ||||||||
| FaxNumber: | 6365270799 | ||||||||
| Practice Location | |||||||||
| Address1: | 3401B RALEIGH ROAD PKWY W | ||||||||
| Address2: | |||||||||
| City: | WILSON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278968217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2522910767 | ||||||||
| FaxNumber: | 2522910921 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 05/02/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GREGG | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2524515324 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | OD | ||||||||
| NPICertificationDate: | 05/02/2022 | ||||||||
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 | 8909165 | 05 | NC | MEDICAID | CA8262 | 01 | NC | RR MEDICARE GROUP | OTHER | 09165 | 01 | NY | BCBSNC GROUP NUMBER | OTHER |