Provider Demographics
NPI:1003966789
Name:TRI CITY OPTOMETRIC, P.A.
Entity Type:Organization
Organization Name:TRI CITY OPTOMETRIC, P.A.
Other - Org Name:TRI CITY OPTOMETRIC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TROY
Authorized Official - Middle Name:N
Authorized Official - Last Name:TEVIS
Authorized Official - Suffix:
Authorized Official - Credentials:OD, PHD
Authorized Official - Phone:828-288-8662
Mailing Address - Street 1:337 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RUTHERFORDTON
Mailing Address - State:NC
Mailing Address - Zip Code:28139-2505
Mailing Address - Country:US
Mailing Address - Phone:828-288-8662
Mailing Address - Fax:828-288-4882
Practice Address - Street 1:337 N MAIN ST
Practice Address - Street 2:
Practice Address - City:RUTHERFORDTON
Practice Address - State:NC
Practice Address - Zip Code:28139-2505
Practice Address - Country:US
Practice Address - Phone:828-288-8662
Practice Address - Fax:828-288-4882
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1807152W00000X, 152WC0802X, 152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Multi-Specialty
No152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89016R5Medicaid
NC24491OtherOPTICARE
NC89012F0Medicaid
NC012F0OtherBCBS GROUP
NC0313616OtherCIGNA HEALTHCARE
NC71877OtherMEDCOST
NC24491OtherOPTICARE
NCU82788Medicare UPIN
NC89016R5Medicaid
NC2342065Medicare PIN