Provider Demographics
NPI:1871691485
Name:CAROLINA FAMILY EYE CARE OF BALLANTYNE, OD, PLLC
Entity type:Organization
Organization Name:CAROLINA FAMILY EYE CARE OF BALLANTYNE, OD, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:LUPINSKI
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:704-295-4444
Mailing Address - Street 1:12105 COPPER WAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-1756
Mailing Address - Country:US
Mailing Address - Phone:704-295-4444
Mailing Address - Fax:704-295-4443
Practice Address - Street 1:12105 COPPER WAY
Practice Address - Street 2:SUITE 100
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-1756
Practice Address - Country:US
Practice Address - Phone:704-295-4444
Practice Address - Fax:704-295-4443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1816152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1816OtherLICENSE
NC89093JHMedicaid
NCU84688Medicare UPIN