Provider Demographics
NPI:1477518066
Name:COVENANT EYE CARE, PA
Entity Type:Organization
Organization Name:COVENANT EYE CARE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:EWING
Authorized Official - Last Name:ALLF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-864-7789
Mailing Address - Street 1:2555 COURT DRIVE
Mailing Address - Street 2:SUITE 150
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-2187
Mailing Address - Country:US
Mailing Address - Phone:704-864-7789
Mailing Address - Fax:704-864-4884
Practice Address - Street 1:2555 COURT DRIVE
Practice Address - Street 2:SUITE 150
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-2187
Practice Address - Country:US
Practice Address - Phone:704-864-7789
Practice Address - Fax:704-864-4884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-18
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC79553207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0265YOtherBCBS
NC890265YMedicaid
NC890265YMedicaid
NC2322797Medicare ID - Type Unspecified