Provider Demographics
NPI:1235387242
Name:MECKLENBURG EYE ASSOCIATES PA
Entity Type:Organization
Organization Name:MECKLENBURG EYE ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE-PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:A
Authorized Official - Last Name:BOLTNICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-334-2020
Mailing Address - Street 1:2015 RANDOLPH RD STE 108
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28207-1200
Mailing Address - Country:US
Mailing Address - Phone:704-334-2020
Mailing Address - Fax:704-334-6175
Practice Address - Street 1:724 ARDEN LN STE 120
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-2995
Practice Address - Country:US
Practice Address - Phone:803-324-2522
Practice Address - Fax:803-324-2522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-03
Last Update Date:2012-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC15966332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
1302440002Medicare NSC