Provider Demographics
NPI:1912934704
Name:SPECTRUM FAMILY EYE CENTER OPTOMETRIC PA
Entity Type:Organization
Organization Name:SPECTRUM FAMILY EYE CENTER OPTOMETRIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LORANCE
Authorized Official - Middle Name:KENNEDY
Authorized Official - Last Name:BURNGARNER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:910-692-3937
Mailing Address - Street 1:160 FOX HOLLOW
Mailing Address - Street 2:
Mailing Address - City:PINEHURST
Mailing Address - State:NC
Mailing Address - Zip Code:28374
Mailing Address - Country:US
Mailing Address - Phone:910-692-3937
Mailing Address - Fax:910-692-5908
Practice Address - Street 1:160 FOX HOLLOW
Practice Address - Street 2:
Practice Address - City:PINEHURST
Practice Address - State:NC
Practice Address - Zip Code:28374
Practice Address - Country:US
Practice Address - Phone:910-692-3937
Practice Address - Fax:910-692-5908
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-27
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0224EOtherBCBS
NC4528892OtherAETNA
NC890224EMedicaid
NC890224EMedicaid
NC890224EMedicaid