Basic Information
| Provider Information | |||||||||
| NPI: | 1902395783 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EYECARECENTER OD PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 207261 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753207261 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6362004393 | ||||||||
| FaxNumber: | 6365270766 | ||||||||
| Practice Location | |||||||||
| Address1: | 5850 US-74 | ||||||||
| Address2: | UNIT 116 | ||||||||
| City: | INDIAN TRAIL | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280790000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6362004393 | ||||||||
| FaxNumber: | 7042347356 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2018 | ||||||||
| LastUpdateDate: | 06/19/2019 | ||||||||
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| AuthorizedOfficialLastName: | GREGG | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
| AuthorizedOfficialMiddleName: | ALLEN | ||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 9197808800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EYECARECENTER OD PA | ||||||||
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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 |
No ID Information.