Provider Demographics
NPI:1972596732
Name:OPTOMETRIC CENTER OF CHARLES CITY PC
Entity Type:Organization
Organization Name:OPTOMETRIC CENTER OF CHARLES CITY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:HOWARD
Authorized Official - Last Name:BURNHAM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:641-228-1732
Mailing Address - Street 1:800 CLARK ST
Mailing Address - Street 2:
Mailing Address - City:CHARLES CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50616-2218
Mailing Address - Country:US
Mailing Address - Phone:641-228-1732
Mailing Address - Fax:641-228-2434
Practice Address - Street 1:800 CLARK ST
Practice Address - Street 2:
Practice Address - City:CHARLES CITY
Practice Address - State:IA
Practice Address - Zip Code:50616-2218
Practice Address - Country:US
Practice Address - Phone:641-228-1732
Practice Address - Fax:641-228-2434
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-26
Last Update Date:2015-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0458463Medicaid
IA0139720001Medicare NSC
IAI8566Medicare PIN