Provider Demographics
NPI:1811024961
Name:PROFESSIONAL EYECARE OPTOMETRY, PA
Entity Type:Organization
Organization Name:PROFESSIONAL EYECARE OPTOMETRY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ERIC
Authorized Official - Last Name:RAYNOR
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:910-423-0700
Mailing Address - Street 1:3701 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HOPE MILLS
Mailing Address - State:NC
Mailing Address - Zip Code:28348-1958
Mailing Address - Country:US
Mailing Address - Phone:910-423-0700
Mailing Address - Fax:910-423-0882
Practice Address - Street 1:3701 S MAIN ST
Practice Address - Street 2:
Practice Address - City:HOPE MILLS
Practice Address - State:NC
Practice Address - Zip Code:28348-1958
Practice Address - Country:US
Practice Address - Phone:910-423-0700
Practice Address - Fax:910-423-0882
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNC1508152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890902FMedicaid
NC890902FMedicaid
NC2468583BMedicare ID - Type Unspecified