Provider Demographics
NPI:1053972877
Name:PROFESSIONAL EYE CARE OPTOMETRY, PA
Entity type:Organization
Organization Name:PROFESSIONAL EYE CARE OPTOMETRY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:ENID
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSARIO-MCCULLOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-423-0700
Mailing Address - Street 1:3701 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HOPE MILLS
Mailing Address - State:NC
Mailing Address - Zip Code:28348-1958
Mailing Address - Country:US
Mailing Address - Phone:910-423-0700
Mailing Address - Fax:910-423-0974
Practice Address - Street 1:432 W BROAD ST
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:NC
Practice Address - Zip Code:28337
Practice Address - Country:US
Practice Address - Phone:910-991-3003
Practice Address - Fax:910-991-3057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-24
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty