Provider Demographics
NPI:1437396454
Name:WENDELL EYE CARE OPTOMETRIC PA
Entity Type:Organization
Organization Name:WENDELL EYE CARE OPTOMETRIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:LUTZ
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:919-366-6599
Mailing Address - Street 1:2495 WENDELL BLVD
Mailing Address - Street 2:
Mailing Address - City:WENDELL
Mailing Address - State:NC
Mailing Address - Zip Code:27591-6903
Mailing Address - Country:US
Mailing Address - Phone:919-366-6599
Mailing Address - Fax:919-366-6355
Practice Address - Street 1:2495 WENDELL BLVD
Practice Address - Street 2:
Practice Address - City:WENDELL
Practice Address - State:NC
Practice Address - Zip Code:27591-6903
Practice Address - Country:US
Practice Address - Phone:919-366-6599
Practice Address - Fax:919-366-6355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-13
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2118152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2473142CMedicare PIN
NC5950747Medicaid
NC6164370001Medicare NSC