Basic Information
| Provider Information | |||||||||
| NPI: | 1962566893 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EYE ASSOCIATES OF WILMINGTON | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | AUSTIN OPTICAL | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1729 NEW HANOVER MEDICAL PARK DR | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284035345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107633601 | ||||||||
| FaxNumber: | 9107634608 | ||||||||
| Practice Location | |||||||||
| Address1: | 1729 NEW HANOVER MEDICAL PARK DR | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284035345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107633601 | ||||||||
| FaxNumber: | 9107634608 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2006 | ||||||||
| LastUpdateDate: | 06/25/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ERICKSON | ||||||||
| AuthorizedOfficialFirstName: | KATHY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9107633601 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 156FX1800X | NC | Y | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Technician/Technologist | Optician |
ID Information
| ID | Type | State | Issuer | Description | 8802045 | 05 | NC | MEDICAID |