Basic Information
| Provider Information | |||||||||
| NPI: | 1932434909 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEBLANC | ||||||||
| FirstName: | MEREDITH | ||||||||
| MiddleName: | BRYNE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GODINO | ||||||||
| OtherFirstName: | MEREDITH | ||||||||
| OtherMiddleName: | BRYNE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | O.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 640 SUMMIT CROSSING PL | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280542138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048653937 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 640 SUMMIT CROSSING PL | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280542138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048653937 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/08/2009 | ||||||||
| LastUpdateDate: | 12/18/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 2152 | NC | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 5915268 | 05 | NC | MEDICAID | 157P0 | 01 | NC | BLUE CROSS BLUE SHIELD | OTHER |