Provider Demographics
NPI:1740727189
Name:EYECARECENTER OD PA
Entity type:Organization
Organization Name:EYECARECENTER OD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:ALLAN
Authorized Official - Last Name:GREGG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:252-451-5324
Mailing Address - Street 1:PO BOX 207261
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75320-7261
Mailing Address - Country:US
Mailing Address - Phone:636-200-4393
Mailing Address - Fax:636-527-0766
Practice Address - Street 1:509 LAUCHWOOD DR
Practice Address - Street 2:
Practice Address - City:LAURINBURG
Practice Address - State:NC
Practice Address - Zip Code:28352-5502
Practice Address - Country:US
Practice Address - Phone:636-200-4393
Practice Address - Fax:910-276-9254
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-24
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0222680043OtherSUPPLIER NUMBER