Provider Demographics
NPI:1447324777
Name:EYEOPTIX OD, PA
Entity type:Organization
Organization Name:EYEOPTIX OD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-714-5338
Mailing Address - Street 1:1960 RANDOLPH ROAD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28207-1129
Mailing Address - Country:US
Mailing Address - Phone:704-372-5332
Mailing Address - Fax:704-714-5343
Practice Address - Street 1:12925 HIGHWAY 601
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:NC
Practice Address - Zip Code:28107-9535
Practice Address - Country:US
Practice Address - Phone:704-888-3937
Practice Address - Fax:704-888-8977
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EYEOPTIX OD, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-20
Last Update Date:2009-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0325550005Medicare NSC