Provider Demographics
NPI:1457511586
Name:WINSTON SALEM OPTOMETRIC GROUP PA
Entity Type:Organization
Organization Name:WINSTON SALEM OPTOMETRIC GROUP PA
Other - Org Name:C DISTINCTIVE EYEWEAR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CALVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:PRESNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-722-5346
Mailing Address - Street 1:302 S STRATFORD RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-1856
Mailing Address - Country:US
Mailing Address - Phone:336-722-5346
Mailing Address - Fax:336-722-5348
Practice Address - Street 1:302 S STRATFORD RD
Practice Address - Street 2:SUITE B
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-1856
Practice Address - Country:US
Practice Address - Phone:336-722-5346
Practice Address - Fax:336-722-5348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-12
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2045152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2346052Medicare UPIN