Provider Demographics
NPI:1497964787
Name:PRIMARY VISION CARE CENTER, O.D., P.A.
Entity Type:Organization
Organization Name:PRIMARY VISION CARE CENTER, O.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:CARL
Authorized Official - Last Name:TART
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:910-803-0555
Mailing Address - Street 1:PO BOX 2429
Mailing Address - Street 2:
Mailing Address - City:SURF CITY
Mailing Address - State:NC
Mailing Address - Zip Code:28443-2149
Mailing Address - Country:US
Mailing Address - Phone:910-803-0555
Mailing Address - Fax:910-338-3160
Practice Address - Street 1:13520 NC HWY 50
Practice Address - Street 2:
Practice Address - City:SURF CITY
Practice Address - State:NC
Practice Address - Zip Code:28445
Practice Address - Country:US
Practice Address - Phone:910-803-0555
Practice Address - Fax:910-338-3160
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1127152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2200320OtherUNITED HEALTH CARE
NC8909890Medicaid
NC09890OtherBLUE CROSS BLUE SHIELD
NC246610EMedicare ID - Type UnspecifiedINDIVIDUAL
NC09890OtherBLUE CROSS BLUE SHIELD
NC2200320OtherUNITED HEALTH CARE