Provider Demographics
NPI:1821715772
Name:PORT CITY OPTOMETRY, PLLC
Entity Type:Organization
Organization Name:PORT CITY OPTOMETRY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RASIKA
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITESELL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:910-200-0635
Mailing Address - Street 1:3259 KELLERTON PL
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28409-4261
Mailing Address - Country:US
Mailing Address - Phone:910-200-0635
Mailing Address - Fax:
Practice Address - Street 1:8035 MARKET ST OFC
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28411-9385
Practice Address - Country:US
Practice Address - Phone:910-200-0635
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-21
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1750717336Medicaid