Provider Demographics
NPI:1619162401
Name:FULLER EYE CARE ASSOCIATES, O.D., P.A.
Entity Type:Organization
Organization Name:FULLER EYE CARE ASSOCIATES, O.D., P.A.
Other - Org Name:TUNNEL ROAD OPTOMETRY GROUP, OD, PA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:828-298-0854
Mailing Address - Street 1:2B HAW CREEK LN
Mailing Address - Street 2:
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28805-2250
Mailing Address - Country:US
Mailing Address - Phone:828-298-0854
Mailing Address - Fax:828-298-2738
Practice Address - Street 1:2B HAW CREEK LN
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28805-2250
Practice Address - Country:US
Practice Address - Phone:828-298-0854
Practice Address - Fax:828-298-2738
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-13
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1477152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890907HMedicaid
NC890907HMedicaid
U40303Medicare UPIN