Basic Information
| Provider Information | |||||||||
| NPI: | 1790937720 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EYE CARE ASSOCIATES OD PA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | EYE CARE ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7100 SIX FORKS RD | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276156156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198470187 | ||||||||
| FaxNumber: | 9196762231 | ||||||||
| Practice Location | |||||||||
| Address1: | 13220 STRICKLAND RD | ||||||||
| Address2: | SUITE 160 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276135213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198706430 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/22/2008 | ||||||||
| LastUpdateDate: | 08/23/2013 | ||||||||
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| AuthorizedOfficialLastName: | BOLICK | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9198470187 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | OD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1692 | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 020X4 | 01 | NC | BLUE CROSS | OTHER | 5950620 | 05 | NC | MEDICAID |