Basic Information
| Provider Information | |||||||||
| NPI: | 1992768758 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GLENDENNING | ||||||||
| FirstName: | TRACEY | ||||||||
| MiddleName: | MORETTE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | O.D | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | MORETTE | ||||||||
| OtherFirstName: | TRACEY | ||||||||
| OtherMiddleName: | ANN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1950 OLD GALLOWS RD | ||||||||
| Address2: | SUITE 520 | ||||||||
| City: | VIENNA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221823990 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038478899 | ||||||||
| FaxNumber: | 7039910514 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 RACINE DR | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284038702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103956050 | ||||||||
| FaxNumber: | 9107942222 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2006 | ||||||||
| LastUpdateDate: | 11/15/2017 | ||||||||
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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 | 1480 | NC | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 410032676 | 01 | NC | RR MEDICARE INDIVIDUAL # | OTHER | 0904G | 01 | NC | BCBS PROV # | OTHER | 890904G | 05 | NC | MEDICAID | 410048231 | 01 | NC | RR MEDICARE INDIVIDUAL # | OTHER |