Provider Demographics
NPI:1649228669
Name:TRIAD EYE ASSOCIATES OD PA
Entity Type:Organization
Organization Name:TRIAD EYE ASSOCIATES OD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:R
Authorized Official - Last Name:GILLIAM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:336-434-4033
Mailing Address - Street 1:PO BOX 4370
Mailing Address - Street 2:
Mailing Address - City:ARCHDALE
Mailing Address - State:NC
Mailing Address - Zip Code:27263-4370
Mailing Address - Country:US
Mailing Address - Phone:336-434-4033
Mailing Address - Fax:336-434-6680
Practice Address - Street 1:10564 N MAIN ST
Practice Address - Street 2:SUITE E
Practice Address - City:ARCHDALE
Practice Address - State:NC
Practice Address - Zip Code:27263-2808
Practice Address - Country:US
Practice Address - Phone:336-434-4033
Practice Address - Fax:336-434-6680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-04
Last Update Date:2008-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC790274PMedicaid
NC0274POtherBCBS/NC
NC2469023Medicare ID - Type UnspecifiedMEDICARE
NC0274POtherBCBS/NC