Provider Demographics
NPI:1700970423
Name:CAROLINA FAMILY EYE CARE OD PLLC
Entity Type:Organization
Organization Name:CAROLINA FAMILY EYE CARE OD PLLC
Other - Org Name:VISION SOURCE STUDIO 20/20
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AMIR
Authorized Official - Middle Name:
Authorized Official - Last Name:KHOSHNEVIS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:704-295-0123
Mailing Address - Street 1:2424 W MALLARD CREEK CHURCH RD
Mailing Address - Street 2:STE D
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-5800
Mailing Address - Country:US
Mailing Address - Phone:704-295-0123
Mailing Address - Fax:704-510-9239
Practice Address - Street 1:2424 W MALLARD CREEK CHURCH RD
Practice Address - Street 2:STE D
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-5800
Practice Address - Country:US
Practice Address - Phone:704-295-0123
Practice Address - Fax:704-510-9239
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1714152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC017GHOtherBLUE CROSS BLUE SHIELD
NC1346242781OtherNPI
NC89093JGMedicaid
NC017GHOtherBLUE CROSS BLUE SHIELD
NC89093JGMedicaid