Provider Demographics
NPI:1295030989
Name:OPTOMETRIC EYE CLINIC, P.A.
Entity Type:Organization
Organization Name:OPTOMETRIC EYE CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PEGGY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:WIKE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:704-664-5406
Mailing Address - Street 1:PO BOX 359
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28115-0359
Mailing Address - Country:US
Mailing Address - Phone:704-664-5406
Mailing Address - Fax:704-663-6498
Practice Address - Street 1:622 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28115-2312
Practice Address - Country:US
Practice Address - Phone:704-664-5406
Practice Address - Fax:704-663-6498
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-11
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1130152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC246501BMedicare PIN