Provider Demographics
NPI:1134441066
Name:PRESTON OPTOMETRY CENTER, PA
Entity type:Organization
Organization Name:PRESTON OPTOMETRY CENTER, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:ROUSSELO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:919-467-4657
Mailing Address - Street 1:258 TOWNE VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27513-8910
Mailing Address - Country:US
Mailing Address - Phone:919-467-4657
Mailing Address - Fax:919-462-0199
Practice Address - Street 1:258 TOWNE VILLAGE DR
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27513-8910
Practice Address - Country:US
Practice Address - Phone:919-467-4657
Practice Address - Fax:919-462-0199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-19
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1466152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1134441066Medicare NSC
NCU42453Medicare UPIN