Basic Information
| Provider Information | |||||||||
| NPI: | 1487807616 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | YADKIN VISION CENTER O.D., PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 225 E LEE AVE | ||||||||
| Address2: | |||||||||
| City: | YADKINVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 270558227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3366792931 | ||||||||
| FaxNumber: | 3366776486 | ||||||||
| Practice Location | |||||||||
| Address1: | 225 E LEE AVE | ||||||||
| Address2: | |||||||||
| City: | YADKINVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 270558227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3366792931 | ||||||||
| FaxNumber: | 3366776486 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2008 | ||||||||
| LastUpdateDate: | 05/06/2021 | ||||||||
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| AuthorizedOfficialLastName: | GORDON | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEMBER/MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3366792931 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | O.D. | ||||||||
| NPICertificationDate: | 05/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 5950718 | 05 | NC | MEDICAID |