Provider Demographics
NPI:1235539099
Name:FRED S CLONINGER OD
Entity Type:Organization
Organization Name:FRED S CLONINGER OD
Other - Org Name:BROAD STREET VISION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FRED
Authorized Official - Middle Name:S
Authorized Official - Last Name:CLONINGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:7041-865-3731
Mailing Address - Street 1:406 S BROAD ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-4304
Mailing Address - Country:US
Mailing Address - Phone:704-865-3731
Mailing Address - Fax:704-864-5736
Practice Address - Street 1:406 S BROAD ST
Practice Address - Street 2:SUITE A
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-4304
Practice Address - Country:US
Practice Address - Phone:704-865-3731
Practice Address - Fax:704-864-5736
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FRED S CLONINGER OD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-08-29
Last Update Date:2014-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0804332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8909163Medicaid
NC0554550001Medicare PIN