Provider Demographics
NPI:1700056066
Name:PROGRESSIVE VISION OPTOMETRIC GROUP P.A.
Entity Type:Organization
Organization Name:PROGRESSIVE VISION OPTOMETRIC GROUP P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST/VICE-PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STACI
Authorized Official - Middle Name:A
Authorized Official - Last Name:PALMER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:336-841-2028
Mailing Address - Street 1:3929 TINSLEY DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:HIGH POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27265-1530
Mailing Address - Country:US
Mailing Address - Phone:336-841-2028
Mailing Address - Fax:336-841-2029
Practice Address - Street 1:3929 TINSLEY DR
Practice Address - Street 2:SUITE 101
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27265-1530
Practice Address - Country:US
Practice Address - Phone:336-841-2028
Practice Address - Fax:336-841-2029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-03
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1689152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC790911AMedicaid
NC790911AMedicaid