Provider Demographics
NPI:1578867057
Name:JACKSONVILLE VISION CENTER, O.D.,PLLC
Entity Type:Organization
Organization Name:JACKSONVILLE VISION CENTER, O.D.,PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:A
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-326-0113
Mailing Address - Street 1:409 WESTERN BLVD
Mailing Address - Street 2:SUITE 700
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-6528
Mailing Address - Country:US
Mailing Address - Phone:910-219-3937
Mailing Address - Fax:
Practice Address - Street 1:409 WESTERN BLVD
Practice Address - Street 2:SUITE 700
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-6528
Practice Address - Country:US
Practice Address - Phone:910-219-3937
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-27
Last Update Date:2011-02-02
Deactivation Date:2011-01-20
Deactivation Code:
Reactivation Date:2011-02-02
Provider Licenses
StateLicense IDTaxonomies
NC1970152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89093R2Medicaid
NC89093R2Medicaid