Provider Demographics
NPI:1336667153
Name:AUSTERO, VIVENCIO CRISOSTOMO JR (LDO, ABOC)
Entity Type:Individual
Prefix:
First Name:VIVENCIO
Middle Name:CRISOSTOMO
Last Name:AUSTERO
Suffix:JR
Gender:M
Credentials:LDO, ABOC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 PLEASANT PLAINS RD
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28104-5958
Mailing Address - Country:US
Mailing Address - Phone:704-401-4793
Mailing Address - Fax:704-821-1363
Practice Address - Street 1:3800 PLEASANT PLAINS RD
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28104-5958
Practice Address - Country:US
Practice Address - Phone:704-401-4793
Practice Address - Fax:704-821-1363
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1050156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician