Basic Information
| Provider Information | |||||||||
| NPI: | 1609909555 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ACADEMY EYE CENTER OPTOMETRY, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1120 RANDOLPH ST | ||||||||
| Address2: | SUITE 32 | ||||||||
| City: | THOMASVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 273605174 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3364750143 | ||||||||
| FaxNumber: | 3364726831 | ||||||||
| Practice Location | |||||||||
| Address1: | 209 W NAOMI ST | ||||||||
| Address2: | |||||||||
| City: | RANDLEMAN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 273171733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3364955700 | ||||||||
| FaxNumber: | 3364951174 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2007 | ||||||||
| LastUpdateDate: | 01/07/2011 | ||||||||
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| AuthorizedOfficialLastName: | RAYNOR | ||||||||
| AuthorizedOfficialFirstName: | DANFORD | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3364600499 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | OD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1464 | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 0853510001 | 01 | NC | CIGNA GOVERNMENT SERVIES MEDICARE PART B DME | OTHER | 011KT | 01 | NC | BCBS GROUP-R | OTHER | 89011KP | 05 | NC | MEDICAID |