Provider Demographics
NPI:1871845172
Name:AMEDCO NORTH CAROLINA LLC
Entity Type:Organization
Organization Name:AMEDCO NORTH CAROLINA LLC
Other - Org Name:GENESIS EYE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GALEN
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAYSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-295-0001
Mailing Address - Street 1:817 E MOREHEAD ST
Mailing Address - Street 2:#200
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28202-2700
Mailing Address - Country:US
Mailing Address - Phone:704-295-0001
Mailing Address - Fax:704-295-0002
Practice Address - Street 1:817 E MOREHEAD ST
Practice Address - Street 2:#200
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28202-2700
Practice Address - Country:US
Practice Address - Phone:704-295-0001
Practice Address - Fax:704-295-0002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-10
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty