Provider Demographics
NPI:1396966602
Name:ACADEMY EYE CENTER OPTOMETRY, PA
Entity type:Organization
Organization Name:ACADEMY EYE CENTER OPTOMETRY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DANFORD
Authorized Official - Middle Name:
Authorized Official - Last Name:RAYNOR
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:336-460-0499
Mailing Address - Street 1:1120 RANDOLPH ST STE 32
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27360-5759
Mailing Address - Country:US
Mailing Address - Phone:336-495-3019
Mailing Address - Fax:336-495-5703
Practice Address - Street 1:108 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BISCOE
Practice Address - State:NC
Practice Address - Zip Code:27209-9526
Practice Address - Country:US
Practice Address - Phone:910-428-4900
Practice Address - Fax:910-428-4909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2011-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1464152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC011KTOtherBCBS GROUP-B
NC89011KTMedicaid
NC085351000OtherCIGNA GOVERNMENT SERVICES MEDICARE PART B DME
NC2471773AMedicare PIN