Provider Demographics
NPI:1164559878
Name:CLERICO OPTOMETRY, P.A.
Entity Type:Organization
Organization Name:CLERICO OPTOMETRY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:CLERICO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:336-924-6811
Mailing Address - Street 1:3528 YADKINVILLE RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106-2535
Mailing Address - Country:US
Mailing Address - Phone:336-924-6811
Mailing Address - Fax:336-922-4375
Practice Address - Street 1:3528 YADKINVILLE RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-2535
Practice Address - Country:US
Practice Address - Phone:336-924-6811
Practice Address - Fax:336-922-4375
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0912152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC09158OtherBLUE CROSS BLUE SHIELD NC
NC8909158Medicaid
NC8909158Medicaid
NC8909158Medicaid