Provider Demographics
NPI:1558543884
Name:EAST CAROLINA OPTOMETRIC CARE, PA
Entity Type:Organization
Organization Name:EAST CAROLINA OPTOMETRIC CARE, PA
Other - Org Name:FRONT STREET OPTOMETRIC CARE, PA
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DOCTOR/OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:L
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:910-540-1969
Mailing Address - Street 1:2322 JAMES B. WHITE HWY NORTH
Mailing Address - Street 2:
Mailing Address - City:WHITEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28472
Mailing Address - Country:US
Mailing Address - Phone:910-914-6442
Mailing Address - Fax:
Practice Address - Street 1:2322 JAMES B WHITE HWY N
Practice Address - Street 2:
Practice Address - City:WHITEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28472
Practice Address - Country:US
Practice Address - Phone:910-914-6442
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-28
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
152W00000X
NC1900152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1900OtherSTATE LICENSE
NC89093N2Medicaid
NC89093N2Medicaid
NCU93961Medicare UPIN