Provider Demographics
NPI:1952419962
Name:HAYWOOD OPTOMETRIC CARE PA
Entity Type:Organization
Organization Name:HAYWOOD OPTOMETRIC CARE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LEROY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-456-7142
Mailing Address - Street 1:29 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WAYNESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28786-3886
Mailing Address - Country:US
Mailing Address - Phone:828-456-8361
Mailing Address - Fax:
Practice Address - Street 1:29 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WAYNESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28786-3886
Practice Address - Country:US
Practice Address - Phone:828-456-8361
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0928152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC22-70673OtherUHC #
NC5856910001OtherDMERC
NC0262BOtherBC/BS
NC1952419962OtherNPI
NC5904769Medicaid
NC=========OtherEIN