Provider Demographics
NPI:1649394891
Name:EYEWEAR UNLIMITED OPTICAL SHOP
Entity Type:Organization
Organization Name:EYEWEAR UNLIMITED OPTICAL SHOP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:BRANCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-723-0748
Mailing Address - Street 1:224 TOWN RUN LN
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27101-3911
Mailing Address - Country:US
Mailing Address - Phone:336-723-0748
Mailing Address - Fax:336-721-4711
Practice Address - Street 1:224 TOWN RUN LN
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-3911
Practice Address - Country:US
Practice Address - Phone:336-723-0748
Practice Address - Fax:336-721-4711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2008-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC21915332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8801843Medicaid