Provider Demographics
NPI:1952635278
Name:WILLANE A. WYLIE, O.D. & ASSOCIATES, P.A.
Entity Type:Organization
Organization Name:WILLANE A. WYLIE, O.D. & ASSOCIATES, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:WILLANE
Authorized Official - Middle Name:ARETTA
Authorized Official - Last Name:WYLIE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:704-575-6796
Mailing Address - Street 1:1948 OROVILLE CT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28214-2567
Mailing Address - Country:US
Mailing Address - Phone:704-575-6796
Mailing Address - Fax:
Practice Address - Street 1:9820 CALLABRIDGE CT
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28216-7669
Practice Address - Country:US
Practice Address - Phone:704-398-9115
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-21
Last Update Date:2009-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1824152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty