Provider Demographics
NPI:1720261662
Name:MOUNT HOLLY EYE CLINIC, OD, PA
Entity Type:Organization
Organization Name:MOUNT HOLLY EYE CLINIC, OD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:FOX-PUTNAM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:704-822-0099
Mailing Address - Street 1:612 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT HOLLY
Mailing Address - State:NC
Mailing Address - Zip Code:28120-1653
Mailing Address - Country:US
Mailing Address - Phone:704-822-0099
Mailing Address - Fax:704-822-0077
Practice Address - Street 1:612 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MOUNT HOLLY
Practice Address - State:NC
Practice Address - Zip Code:28120-1653
Practice Address - Country:US
Practice Address - Phone:704-822-0099
Practice Address - Fax:704-822-0077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-13
Last Update Date:2010-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1387152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890928GMedicaid
NC0928GOtherBLUE CROSS/BLUE SHIELD
NC12304OtherSPECTERA
NC4622OtherDAVIS VISION
NCOP0469OtherEYEMED
NCNC 1387OtherVISION BENEFITS OF AMERIC
NC4622OtherDAVIS VISION
NC2467474CMedicare PIN
NCNC 1387OtherVISION BENEFITS OF AMERIC