Provider Demographics
NPI:1588619217
Name:CLARK OPTOMETRIC CENTER PA
Entity Type:Organization
Organization Name:CLARK OPTOMETRIC CENTER PA
Other - Org Name:TRIANGLE VISIONS OPTOMETRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:919-544-2020
Mailing Address - Street 1:2216 NC E HWY 54
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713
Mailing Address - Country:US
Mailing Address - Phone:919-544-2020
Mailing Address - Fax:919-433-0298
Practice Address - Street 1:2216 NC E HWY 54
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713
Practice Address - Country:US
Practice Address - Phone:919-544-2020
Practice Address - Fax:919-433-0298
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2023-04-14
Deactivation Date:2023-04-03
Deactivation Code:
Reactivation Date:2023-04-14
Provider Licenses
StateLicense IDTaxonomies
152W00000X
NC1860152W00000X
NC1385152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8909922Medicaid
NC0777330001Medicare NSC
NC2468905Medicare ID - Type Unspecified