Provider Demographics
NPI:1518140672
Name:CAROLINA EYE CARE OD PA
Entity Type:Organization
Organization Name:CAROLINA EYE CARE OD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, CAROLINA EYE CARE
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:LAFONE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:704-892-3542
Mailing Address - Street 1:19607 W CATAWBA AVE
Mailing Address - Street 2:
Mailing Address - City:CORNELIUS
Mailing Address - State:NC
Mailing Address - Zip Code:28031-4002
Mailing Address - Country:US
Mailing Address - Phone:704-892-3542
Mailing Address - Fax:704-896-8528
Practice Address - Street 1:19607 W CATAWBA AVE
Practice Address - Street 2:
Practice Address - City:CORNELIUS
Practice Address - State:NC
Practice Address - Zip Code:28031-4002
Practice Address - Country:US
Practice Address - Phone:704-892-3542
Practice Address - Fax:704-896-8528
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-12
Last Update Date:2012-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1865152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCDE9560OtherRETIRED RAILROAD MEDICARE
NC1266020004OtherDMERC REGION C
NC2468721Medicare PIN