Provider Demographics
NPI:1376576777
Name:NORTH CAROLINA CORRECTION ENTERPRISES OPTICAL
Entity Type:Organization
Organization Name:NORTH CAROLINA CORRECTION ENTERPRISES OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORRECTION ENTERPRISES DIRECTOR II
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:H
Authorized Official - Last Name:LEON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-716-3647
Mailing Address - Street 1:2869 US HIGHWAY 64A
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27856-8765
Mailing Address - Country:US
Mailing Address - Phone:888-388-1353
Mailing Address - Fax:252-459-7400
Practice Address - Street 1:2869 US HIGHWAY 64A
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:NC
Practice Address - Zip Code:27856-8765
Practice Address - Country:US
Practice Address - Phone:888-388-1353
Practice Address - Fax:252-459-7400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8802023Medicaid
NC332H00000XOtherPROVIDER TOXONOMY CODE