Provider Demographics
NPI:1093234007
Name:TRIAD PEDIATRIC EYE PHYSICIANS PC
Entity Type:Organization
Organization Name:TRIAD PEDIATRIC EYE PHYSICIANS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:HEIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-245-8320
Mailing Address - Street 1:2554 LEWISVILLE CLEMMONS RD STE 308
Mailing Address - Street 2:
Mailing Address - City:CLEMMONS
Mailing Address - State:NC
Mailing Address - Zip Code:27012-8749
Mailing Address - Country:US
Mailing Address - Phone:336-245-8320
Mailing Address - Fax:336-293-4857
Practice Address - Street 1:2554 LEWISVILLE CLEMMONS RD STE 308
Practice Address - Street 2:
Practice Address - City:CLEMMONS
Practice Address - State:NC
Practice Address - Zip Code:27012-8749
Practice Address - Country:US
Practice Address - Phone:336-245-8320
Practice Address - Fax:336-293-4857
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207W00000X
NC2010-01965207WX0110X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0110XAllopathic & Osteopathic PhysiciansOphthalmologyPediatric Ophthalmology and Strabismus SpecialistGroup - Multi-Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty