Provider Demographics
NPI:1386866762
Name:TUNNEL ROAD OPTOMETRY GROUP
Entity Type:Organization
Organization Name:TUNNEL ROAD OPTOMETRY GROUP
Other - Org Name:ADVANCED EYE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:G
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:336-765-5350
Mailing Address - Street 1:3316 SILAS CREEK PKWY
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-3011
Mailing Address - Country:US
Mailing Address - Phone:336-765-5350
Mailing Address - Fax:336-765-0769
Practice Address - Street 1:3702 W GATE CITY BLVD
Practice Address - Street 2:ADVANCED EYE CARE
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27407-4628
Practice Address - Country:US
Practice Address - Phone:336-854-2020
Practice Address - Fax:336-852-9472
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5916691Medicaid
NC5916691Medicaid