Provider Demographics
NPI:1871468413
Name:FAIRMONT EYE CLINIC OD PLLC
Entity type:Organization
Organization Name:FAIRMONT EYE CLINIC OD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:910-628-8316
Mailing Address - Street 1:PO BOX 648
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:NC
Mailing Address - Zip Code:28340-0648
Mailing Address - Country:US
Mailing Address - Phone:910-628-8316
Mailing Address - Fax:910-628-5642
Practice Address - Street 1:204 IONA ST
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:NC
Practice Address - Zip Code:28340-1616
Practice Address - Country:US
Practice Address - Phone:910-628-8316
Practice Address - Fax:910-628-5642
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-10-06
Last Update Date:2025-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty