Provider Demographics
NPI:1376722231
Name:KOALA EYE CENTRE PC
Entity Type:Organization
Organization Name:KOALA EYE CENTRE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ANTONIO
Authorized Official - Last Name:SPENCER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-378-2511
Mailing Address - Street 1:719 GREEN VALLEY RD
Mailing Address - Street 2:STE. 303
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27408-7014
Mailing Address - Country:US
Mailing Address - Phone:336-378-2511
Mailing Address - Fax:336-378-1186
Practice Address - Street 1:719 GREEN VALLEY RD
Practice Address - Street 2:STE. 303
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27408-7014
Practice Address - Country:US
Practice Address - Phone:336-378-2511
Practice Address - Fax:336-378-1186
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-29
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200100470261QS0132X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0132XAmbulatory Health Care FacilitiesClinic/CenterOphthalmologic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8913132Medicaid
NC2328003Medicare PIN