Provider Demographics
NPI:1225039340
Name:CHAMBERLAIN, LIONEL NELSON (OD)
Entity Type:Individual
Prefix:
First Name:LIONEL
Middle Name:NELSON
Last Name:CHAMBERLAIN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 648
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:NC
Mailing Address - Zip Code:28340-0648
Mailing Address - Country:US
Mailing Address - Phone:910-628-8316
Mailing Address - Fax:910-628-5642
Practice Address - Street 1:204 IONA ST
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:NC
Practice Address - Zip Code:28340-1616
Practice Address - Country:US
Practice Address - Phone:910-268-8316
Practice Address - Fax:910-628-5642
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2008-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC832152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8909145Medicaid
0353960001OtherPALMETTO GBA
0353960001OtherPALMETTO GBA
NC8909145Medicaid
246014Medicare PIN