Provider Demographics
NPI:1134156821
Name:AYCOCK EYE ASSOCIATES OD PA
Entity type:Organization
Organization Name:AYCOCK EYE ASSOCIATES OD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUE
Authorized Official - Middle Name:W
Authorized Official - Last Name:AYCOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-283-2179
Mailing Address - Street 1:120 E PHIFER STREET
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NC
Mailing Address - Zip Code:28110-3035
Mailing Address - Country:US
Mailing Address - Phone:704-283-2179
Mailing Address - Fax:704-283-8314
Practice Address - Street 1:120 E PHIFER STREET
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28110-3035
Practice Address - Country:US
Practice Address - Phone:704-283-2179
Practice Address - Fax:704-283-8314
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0801152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8909026Medicaid
NC246167AMedicaid
NC8909026Medicaid